_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Skills and Qualifications -
Comments
Traffic Convictions and Forfeitures for the past 3 years other than parking violations
Employment Record
Accident Review for past 3 years
Driving Experience
DRIVER EXPERIENCE & QUALIFICATION
Additional Information
References
Educational Background
Earp Distribution -- Application for Employment -- Driver
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.
Name of source (if applicable)
Referral Source
Position(s) applied for
Date of application
Walk-in
Other
Government Employment Agency
Relative
Private Employment Agency
Employee
Advertisement
Was it a felony? . . . . .
Middle Name
Zip Code
Zip Code
NAME
TELEPHONE
YEARS KNOWN
ORGANIZATION
OFFICES HELD
A. SCHOOL
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
TELEPHONE
TELEPHONE
MAY WE CONTACT FOR REFERENCE?
REASON FOR LEAVING
IMMEDIATE SUPERVISOR and TITLE
JOB TITLE
ADDRESS
EMPLOYER
EMPLOYER
FINAL $
STARTING $
PER
PER
HOURLY RATE/SALARY
DATES EMPLOYED FROM ---- TO
B. YEARS COMPLETED
C. DEGREE DIPLOMA
D. GPA CLASS RANK
E. MAJOR
F. MINOR
State
State
City
City
First Name
Cell# / Other#
If yes, work number and best time to call . . . . . . . . . . . . . . . . .
To
If not, how long since leaving last employment?
If yes, give dates . . . . . From
If yes, give date(s)
Will you relocate if job requires it?
Names of any relatives employed by this company:
If yes, reason for leaving.
Are you currently employed?
Have you ever been employed here before?
Have you submitted an application before?
If no, please explain
If necessary, the best time to call you at home is
* If at the above residence less than three years, list below all residences for the past seven years.
Telephone#
Street Address
Street Address
Last Name
PM
PM
AM
AM
Type of employment desired?
EXCLUDE MEMBERSHIPS WHICH WOULD REVEAL SEX, RACE, RELIGION, NATIONAL ORIGIN, AGE, COLOR, DISABILITY OR ANY OTHER SIMILARLY PROTECTED STATUS.
EXCLUDE MEMBERSHIPS WHICH WOULD REVEAL SEX, RACE, RELIGION, NATIONAL ORIGIN, AGE, COLOR, DISABILITY OR ANY OTHER SIMILARLY PROTECTED STATUS.
CONVICTION WILL NOT NECESSARILY BE A BAR TO EMPLOYMENT. EACH INSTANCE AND EXPLANATION WILL BE CONSIDERED IN RELATION TO THE POSITION FOR WHICH YOU ARE APPLYING.
AN EQUAL OPPORTUNITY EMPLOYER
IF JOB RELATED
Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.
Start with most recent or current position including military experience, and work backwards.
The U.S. Department of Transportation requires that driver applications show all employment for the past three years. Those applying for a position requiring a CDL must show employment history for 10 years prior to the date of this application. 391.21(B)(10), 11)
List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
A. List last three(3) schools attended, starting with most recent. B. List number of years completed. C. Indicate degree or diploma earned, if any. D. Grade Point Average or Class Rank. E. Major field of study. F. Minor field of study (if applicable).
If yes, please explain
The U.S. Department of Transportation requires that driver applicants state their date of birth (391.21(b)(2))
Drivers Licenses held in past 3 years must be shown.
Date of Birth
(Head-On, Rear-End, Overturn, etc.)
Date
Nature of accident
Type of Equipment (Van, Tank, Flat, etc.)
Location
Dates
Class of Equipment
Date From
Charge
Fatalities
Date To
Penalty
Injuries
Approximate Total Miles
State
License No.
Class
Endorsements
Expiration Date
If no, please explain
Date available for work
Are you legally eligible for employment in this country?
Will you work overtime if required? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
Yes
C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?
List driving awards held and who awards were presented by:
List special courses or training that will help you as a driver:
List states operated in during last five years:
If you answered yes to A,B, or C then give details here:
B. Has any license, permit, or privilege ever been suspended or revoked? . . . . . . . . . . . . . . . . . . . . . .
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? . . . . . . . . .
Have you ever been bonded? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If so, under what name?
Was it a felony? . . . . .
Have you ever worked for this company under another name?
Have you been convicted of a crime? . . . . . . .
Are you able to meet the attendance requirements of the position? . . . . . . . . . . . . . . . . . . . . . . . . . .
If you are under 18 and it is required, can you furnish a work permit? . . . . . . . . . . . . . . . . . . . . . . . . . .
May we contact you at work? . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
Yes
No
No
No
No
No
Yes
Later
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Full-Time
Part-Time
Temporary
Seasonal
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
____________________________________________
List professional, trade, business, or civic associations and any offices held.
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
List special accomplishments, publications, awards, etc.
List any additional information you would like us to consider.
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
INCLUDING EXPLANATION OF ANY GAPS IN EMPLOYMENT
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
Street Address
City
State
Zip Code
Street Address
City
State
Zip Code
Street Address
City
State
Zip Code
Street Address
City
State
Zip Code
Street Address
City
State
Zip Code
Street Address
City
State
Zip Code
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER
EMPLOYER
TELEPHONE
DATES EMPLOYED FROM ---- TO
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
ADDRESS
JOB TITLE
IMMEDIATE SUPERVISOR and TITLE
HOURLY RATE/SALARY
REASON FOR LEAVING
STARTING $
PER
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
FINAL $
PER