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					                                              Application for Employment
                                       Lien Transportation Company
                                                PO Box 40
                                            Aberdeen, SD 57402
                                        Phone 605-225-3814 Ext. # 11
                              CDL (Commercial Drivers License) Application
                        This application is for ALL applicants that have a CDL License, whether you are
                                         applying for a driver position or other position.

PLEASE PRINT
 Position(s) Applied For
 _____ Laborer _____ Equip Operator _____ Driver _____ Carpenter _________________ Other

 Referral Source
                   _____ Advertisement   _____ Walk-In       ______ Private Employment Agency
                   _____ Employee        _____ Other         _____ Gov’t Employment Agency

 Name Of Source (if applicable) ___________________________________________


Name: _______________________________
Address: ____________________ City: ___________________
State: _____________ ZIP: ____________________
Telephone Number(s): Home: (____) _______________ Cell: (___) ____________
Social Security Number: ________________________________________
Best time to contact you: ____________________________
If hired, Emergency number: (___) ___________
Emergency Contact Person: ______________________ Relation: ____________
Have you filled out an application here before? _____ Yes _____ No
If yes, give date: _____/_____/_____
Have you ever been employed here before? _____ Yes, ____NO, What position Held _______.
If yes, give dates: From _____ /_____/_____ to ______ /_____ /_____
Are you legally eligible for employment in this country? _____Yes _____ No
        (Proof of U.S. Citizenship or immigration status will be required upon employment)

Are you presently employed? _____Yes _____ No
May we contact your present employer? _____ Yes _____ NO, if No, Why? _______________
Date available for work: _____/_____/_____
Have you been convicted of a felony in the last seven (7) years? _____ Yes _____ No
        (Such conviction may be relevant if job related, but does not bar you from employment)
If yes, please explain:
________________________________________________________________________________
________________________________________________________________________________.

Do you have a valid driver’s license? _____ Yes _____ No What State: ________ Class: ____.
Driver’s License Number: ______________________ Endorsement: _______________________
High School Diploma: _____ Yes _____ No                   GED: _____ Yes _____ No




                                                         1
REFERENCES

List name and telephone number of three business/work references that are not related to you.

 NAME                                     TELEPHONE                       YEARS KNOWN




SKILLS AND QUALIFICATIONS – Summarize any special training, skills, licenses, certificates, and/or
characteristics of yourself that may qualify you as being able to perform job-related functions for the
position which you are applying.
_____________________________________________________________________________________.

______________________________________________________________________________________.

LIST THE TYPES OF MACHINERY/EQUIPMENT YOU HAVE OPERATED
_____________________________________________________________________________________.

_____________________________________________________________________________________.

LIST ANY ADDITIONAL INFORMATION YOU WOULD LIKE US TO CONSIDER
_____________________________________________________________________________________.

_____________________________________________________________________________________.
ADDITIONAL COMMENTS
_____________________________________________________________________________________.

_____________________________________________________________________________________.

Most of our jobs require lifting of heavy objects, shoveling dirt, gravel, asphalt mix,
and operation of equipment. Are you able to perform these duties?
                      ______Yes ________No

Some of our jobs are performed several miles from any emergency care. Are there any pre-existing
medial conditions we need to be made aware of in case an injury may occur on the job.
          ________Yes (If yes please list conditions or limitations below.)  _______No

_____________________________________________________________________.




                                                      2
EMPLOYMENT HISTORY

List the last three (3) employers, assignments or volunteer activities, starting with the most recent, including
military experience. Explain any gaps in employment in the comments section on the next page.
CDL Applicants must provide the last 10 years of Commercial driving employment.
 Employer                                               Telephone (       )


 Address                                                Dates
                                                        From          /   /      to       /      /
 Immediate Supervisor and Title                         Wage
                                                                  $
 Job Title/Duties

 Reason for Leaving


 May we contact for reference?
                                              Yes               No            Later



 Employer                                               Telephone (       )


 Address                                                Dates
                                                        From          /   /      to       /      /
 Immediate Supervisor and Title                         Wage
                                                                  $
 Job Title/Duties

 Reason for Leaving


 May we contact for reference?
                                              Yes               No            Later



 Employer                                               Telephone (       )


 Address                                                Dates
                                                        From          /   /      to       /      /
 Immediate Supervisor and Title                         Wage
                                                                  $
 Job Title/Duties

 Reason for Leaving


 May we contact for reference?
                                              Yes               No            Later


If more room is needed please use the back side if this page.




                                                          3
CDL License information

Class: ________________      Expiration Date: _______________.

Do you have a health card? _____ Yes      _____ No

DRIVING EXPERIENCE
      CLASS OF               TYPE                    DATES
     EQUIPMENT        (VAN, TRUCK, ETC)   FROM            TO      APPROX. MILES

 STRAIGHT TRUCK

 TRACTOR/SEMI

 TRACTOR/ 2 TRAILER

 OTHER

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE
(ATTACH SHEET IF MORE SPACE IS NEEDED)

                       NATURE OF ACCIDENT
         DATES        HEAD-ON, REAR-END ETC          FATALITIES    INJURIES

LAST ACCIDENT:


NEXT PREVIOUS:


NEXT PREVIOUS:


TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS
      (OTHER THAN PARKING TICKETS)
     LOCATION              DATE              CHARGE                PENALTY




A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
                    _____ Yes       _____ No

B. Has any license, permit or privilege ever been suspended or revoked?
                      _____ Yes       _____ No

IF THE ANSWER TO EITHER A OR B IS YES, ATTACH A STATEMENT OF DETAILS.



                                                 4
                           CONFIDENTIAL PAST EMPLOYER INQUIRY

Waiver
I hereby authorize the below named company to release the above information to Lien Transportation
Company (or their authorized agents) for the purposes of investigation as required by Section 391.23
and 382.413 of the Federal Motor Safety Regulations. I hereby release the below named company and
it’s employees, officers, directors and agents from any and all liability of any type as a result of
providing the requested information to Lien Transportation Company.

_______________________________________________           __________________________________
  Applicant’s Signature              Date                    Witnesses Signature    Date


To Whom It May Concern:

The person named above has applied to Lien Transportation Company for qualification in a safety
sensitive position. Your firm is listed by the applicant as a past employer. As you will note from the
waiver stated above, all liability of you, and your company has been released by the applicant. You
may reply by facsimile to the fax number listed below. Thank you in advance for your response to this
inquiry.

Name of Applicant: _________________________________ SS # _________________________

Dates of Qualification _____________________ to __________________

      Are the above qualifications dates correct? Yes _______ No ______
               Correct Dates ________________ to _________________

      Did he/she drive a Tractor-Semi Trailer?   Yes ________   No ___________

      Type of Trailer? Van ______ Reefer _______ Tanker _______ Flat _____ Other ______

      Total Number of Accidents? _______ Preventable? _______ Non-Preventable? ______

      Reason for Leaving Your Company? Resigned _____ Discharged ______ Layoff ______

      Eligible for Re-hire? Yes ______ No ______ upon Review ______

      Has the person ever tested positive for controlled substance
      In the past two years during their qualification with your company? Yes _____ No _____

      Has the person ever had a breath alcohol test with a result of .04 or greater
      In the past two years during their qualification with your company? Yes _____ No _____

      Has this person ever refused a required test for drugs or alcohol in the
      Past two years during their qualification with your company? Yes ______ No_____

If yes to any of the above questions, please release any documentation relating to the SAP Evaluation,
determination and compliance, and give the SAP’s name, address and phone number for further
reference.
SAP Name ___________________________________SAP Phone __________________________

SAP address/city/state/Zip ___________________________________________________________
Signature of Person supplying information: __________________________________________

      Title: __________________________________        Date: _______________________
                                                   5
                                Motor Vehicle Record
                               Disclosure and Release
In connection with my ongoing employment or my application for employment, should I have
or secure a position with Lien Transportation Co., I understand that a motor vehicle record,
which contains public record information, maybe requested. I further understand that such
report(s) will contain personal information and public record information concerning my
driving record from federal, state and other agencies that maintain such records, as well as
independent services that provide driving record information.

I authorize, without reservation, any party or agency contacted to furnish the above mentioned
information to Insurance Plus, or its agent.

I hereby authorize procurement of my motor vehicle report. If hired, this authorization shall
remain on file and shall serve as ongoing authorization for you to procure such reports at any
time during my employment. Lien Transportation Co.’s commercial auto insurer and agent
will also use this information in conjunction with loss control and safety review efforts.




   _________________________________                          _______________________
   Full Legal Name (include middle initial)                    Social Security Number



   _________________________________                          _______________________
     Drivers License Number                                         Date of Birth



   ________________________________
       State of Issuance



   ________________________________                           _________________________
     Signature                                                      Date




                                               6
It is understood and agreed upon that any misrepresentation by me on this application will be
sufficient cause for cancellation of this application and/or separation from the employer’s
service if I have been employed.

I give the employer the right to investigate all references and to secure additional information
about me, if job related. I hereby release from liability the employer and its representatives for
seeking such information and all other persons, corporations or organizations for furnishing
such information.

The employer is an Equal Opportunity Employer. The employer does not discriminate in
employment and no question on this application is used for the purpose of limiting or
excusing any applicant’s consideration for employment on a basis prohibited by local, state or
federal law.

Lien’s considers all applicants for all positions without regard to race, color, religion, creed,
gender, national origin, age, disability, marital status, sexual orientation, or any other legally
protected status.

I understand that just as I am free to resign at any time, the employer reserves the right to
terminate my employment at any time with or without good cause and without prior notice. I
understand that no representative of the employer has the authority to make any assurance to
the contrary.

I understand it is this company’s policy not to refuse to hire a qualified individual with a
disability because of this person’s need for an accommodation that would be required by the
ADA.




 ___________________________________           _________/__________/__________
  Signature of Applicant                       Date


                     (NOTE: APPLICATIONS KEPT ON FILE FOR 60 DAYS.)




                                                 7
                          AFFIRMATIVE ACTION VOLUNTARY INFORMATION

===============================================================================================.


We consider applicants for all positions without regard to race, color, religion, sex, national
origin, age, disability, veteran status or any other legally protected status.

==============================================================.
To be completed by applicant. Not for interview purposes. To be filed separately from
application. This information is used to satisfy the Affirmative Action requirements of Section
503 of the Rehabilitation act or as necessitated by another federal law or regulation.

As required, we comply with government regulations including Affirmative Action obligations
where they apply.

In an effort to comply with requirements regarding government record keeping, reporting and
other legal obligations, we ask that you complete this applicant data survey. Your
cooperation is appreciated.

Please be advised that this survey is not part of your official application for employment. It is
considered confidential information that will not be used in any hiring decision.

==============================================================.
APPLICANT INFORMATION
Name ___________________________________ Phone (____) ___________

Address _________________________________ City ___________________                                 State _____
ZIP _________

     _____ Male          _____ Female

PLEASE CHECK ONE OF THE FOLLOWING EQUAL EMPLOYMENT OPPORTUNITY
IDENTIFICATION GROUPS

   _____ White    _____ Black (not of Hispanic origin) _____ Hispanic
   _____ American Indian/Alaskan Native                _____ Asian/Pacific Islander
===============================================================.
SPECIAL NOTICE

To Vietnam Era Veterans, Disabled Veterans and Individuals with physical or mental disabilities:

Government contractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and
Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment
qualified disabled veterans, veterans of the Vietnam era and qualified handicapped individuals.

You are invited to volunteer this information, if you qualify, to assist in proper placement and
determining reasonable accommodation. This information will be considered confidential. Refusal to
provide this information will not adversely affect your consideration for employment.

If you wish to be identified, please check if any of the following are applicable:
   _____ Vietnam Era Veteran                  _____ Disabled Veteran
   _____ (served between 1964-1975)           _____ Individual with a disability


                                                         8

				
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