Employment Application

A Full Service Traffic Control Company

APPLICANT: PLEASE READ AND SIGN BEFORE SUBMITTING THIS APPLICATION.

I understand that the information in this application will be used and that prior employers will be contacted for purposes of investigation required by 391.23 of the Motor Carrier Safety Regulations.

ADDRESS FOR PAST THREE YEARS (If Different then above)

EMERGENCY NOTIFICATION

SELECT HIGHEST GRADE COMPLETED

HAVE YOU WORKED FOR THIS COMPANY BEFORE ?

IS THERE ANY REASON YOU MIGHT BE UNABLE TO PERFORM THE FUNCTIONS OF THE JOB FOR WHICH YOU HAVE APPLIED ?

YES NO

DO YOU HAVE ANY MEDICAL OR PHYSICAL CONDITIONS (PRIOR OR CURRENT) THAT WOULD AFFECT YOUR ABILITY TO PERFORM ALL OF THE DUTIES AND REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING?

YES NO

ATTACH SHEET IF MORE SPACE IS NEEDED (D.O.T. REQUIRES THAT EMPLOYMENT FOR PAST 10 YEARS BE SHOWN)

WERE YOU SUBJECT TO THE FMCRst WHILE EMPLOYED

YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOLTESTING REQUIREMENTS OF 49 CFR PART 40?

YES NO

SECOND LAST EMPLOYER

WERE YOU SUBJECT TO THE FMCRst WHILE EMPLOYED

YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOLTESTING REQUIREMENTS OF 49 CFR PART 40?

YES NO

WERE YOU SUBJECT TO THE FMCRst WHILE EMPLOYED

YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOLTESTING REQUIREMENTS OF 49 CFR PART 40?

YES NO

EXPERIENCE AND QUALIFICATIONS- DRIVER

DRIVER LICENSES HELD IN PAST 3 YEARS MUST BE SHOWN

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

YES NO

Has any license, permit or privilege ever been suspended or revoked?

YES NO

In the past 5 years have you had any tickets, accidents or DUI’s?

YES NO

TRACTOR/SEMI TRAILER

ACCIDENT RECORD FOR PAST 5 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED)

TRAFFIC CONVICTIONS AND FORFEITURES FOR PAST 5 YEARS (OTHER THAN PARKING VIOLATIONS)

TO BE READ AND SIGNED BY APPLICANT

It is agreed and understood that any misrepresentations and information given above shall be considered an act of dishonesty and may result in termination. It is agreed and understood that that the employer and its agents may investigate the applicants background to ascertain and all information of concern to applicants record, whether same is of record or not and applicant release employers and persons named herein from all liability for any damages on account of his furnishing such information. The applicant agrees to furnish such additional information and complete such examinations as may be required to complete his employment file. It is agreed and understood that application for employment in no way obligates the employer to employ the applicant. It is agreed and understood that if hired, the employee may be on a probationary period during which time he may be discharged without recourse.

This certifies that this application was completed by me and that all entries and information on it are true and complete to the best of my knowledge.