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Lies of Omission on Job Application document sample
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DRIVER’S EMPLOYMENT APPLICATION
_________________________________________________________________________________________
PO Box 24606, Seattle, WA 98124
In compliance with Federal, State and Local Equal Opportunity Employment Laws, this Company does not unlawfully
discriminate on the basis of race, color, religion, sex, national origin, age, marital status, sexual orientation, veteran status,
disability status, or any other basis prohibited by Federal, State or Local Law. Please let us know if you need
accommodations to participate in the application process.
______________________________________________________________________ TODAY’S DATE ______________________
NAME SOCIAL SECURITY NUMBER __________-__________- _____
PHONE NUMBER (__________) __________-_____________ E-MAIL ADDRESS ______________________________________
CURRENT ADDRESS CITY, STATE, ZIP _________________________________________
PREVIOUS ADDRESSES: LIST YOUR ADDRESSES OF RESIDENCY FOR THE PAST THREE (3) YEARS
ADDRESS CITY, STATE, ZIP HOW LONG (MM/YY) __________
ADDRESS CITY, STATE, ZIP HOW LONG (MM/YY) _____________
ADDRESS CITY, STATE, ZIP HOW LONG (MM/YY) __________
IN CASE OF EMERGENCY, PLEASE NOTIFY: NAME _____________________________________________________
PHONE NUMBER (_________) _________- ADDRESS _______________________________________________
ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES? _______________________________________________
CAN YOU FURNISH PROOF OF EMPLOYMENT ELIGIBILITY? ____________________________________________________________
DATE OF BIRTH (REQUIRED FOR COMMERCIAL DRIVERS) CAN YOU PROVIDE PROOF OF AGE? _______________
ARE YOU ABLE TO PERFORM THE ESSENTIAL JOB FUNCTIONS OF THE POSITION YOU ARE APPLYING FOR WITH OR WITHOUT
REASONABLE ACCOMMODATION? __YES __NO
HOW DID YOU HEAR OF THIS POSITION? NEWSPAPER INTERNET REFERRAL OTHER
HAVE YOU EVER BEEN INTERVIEWED OR EMPLOYED BY TRIPLE B CORP ___YES ____NO
DBA: CHARLIE’S PRODUCE, ROGGE, ALASKA CARROT CO, ST PRODUCE, ALASKA ROGGE, OR HIGHLINER FOOD SERVICE
IF YES, PLEASE PROVIDE THE DETAILS ____________________________________________________________________________
DO YOU HAVE ANY RELATIVES EMPLOYED BY TRIPLE B CORP OR ITS AFFILIATES? ___YES _____NO IF YES, PLEASE PROVIDE
NAME RELATIONSHIP ______________________________________
RATE OF PAY EXPECTED: CAN YOU WORK FULL TIME? _______________________ PART TIME?_________________
CAN YOU WORK NIGHTS?___________ WEEKENDS? CAN YOU WORK OVER-TIME? __________________
WHEN CAN YOU START WORK? DO YOU HAVE ANY VACATION PLANS? ________________________________________
ARE YOU CURRENTLY EMPLOYED? _______IF YES, HOW MUCH NOTICE WOULD YOU HAVE TO GIVE?______________________
Rev. 04/03/2007
EMPLOYMENT FOR THE LAST 10 YEARS
Use the back side of this page if more than 4 employers in the last 10 years
PLEASE LIST YOUR WORK EXPERIENCE FOR THE PAST FIVE YEARS BEGINNING WITH YOUR MOST RECENT JOB HELD. LIST COMPLETE
MAILING ADDRESSES, STREET NUMBER, CITY, STATE AND ZIP CODE. NOTE: IF YOU HAVE WORKED FOR MORE THAN THREE
EMPLOYERS OVER THE LAST TEN YEARS, PLEASE LIST OTHERS ON THE BACK OF THIS SHEET. YOU MAY ATTACH A RESUME BUT NOT
IN PLACE OF COMPLETING THE REQUIRED INFORMATION
ALL DRIVER APPLICANTS TO DRIVE A COMMERCIAL MOTOR VEHICLE* IN INTRASTATE OR INTERSTATE COMMERCE
SHALL ALSO PROVIDE WORK EXPERIENCE INFORMATION FOR AN ADDITIONAL 5 YEARS ON THOSE EMPLOYERS FOR WHICH
THE APPLICANT OPERATED SUCH A VEHICLE.
* INCLUDES VEHICLES HAVING A GVWR OF 26,001 LBS. OR MORE, VEHICLES DESIGNED TO TRANSPORT 16 OR MORE PASSENGERS
(INCLUDING DRIVER), OR ANY SIZE VEHICLE USED TO TRANSPORT HAZARDOUS MATERIALS IN A QUANTITY REQUIRING
PLACARDING.
EMPLOYER NAME______________________________________ PHONE NUMBER (__________) __________-__________
ADDRESS_________________________________________________IMMEDIATE SUPERVISOR _____________________________
POSITION HELD FROM ________TO ________ PAY OR SALARY START FINAL_____
WERE YOU SUBJECT TO THE FMCSRS† WHILE EMPLOYED? YES NO
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND
ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
POSITION RESPONSIBILITIES AND DUTIES:
_________________________________________________________________________
REASON FOR LEAVING (BE SPECIFIC): ____________________________________________________________________________
PLEASE EXPLAIN ANY GAPS OF EMPLOYMENT OVER 2 WEEKS _________________________________________________________
EMPLOYER NAME______________________________________ PHONE NUMBER (__________) __________-__________
ADDRESS_________________________________________________IMMEDIATE SUPERVISOR _____________________________
POSITION HELD FROM ________TO ________ PAY OR SALARY START FINAL_____
WERE YOU SUBJECT TO THE FMCSRS† WHILE EMPLOYED? YES NO
WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO
THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
POSITION RESPONSIBILITIES AND DUTIES:
_________________________________________________________________________
REASON FOR LEAVING (BE SPECIFIC): ____________________________________________________________________________
PLEASE EXPLAIN ANY GAPS OF EMPLOYMENT OVER 2 WEEKS __________________________________________________
Rev. 04/03/2007
EMPLOYER NAME______________________________________ PHONE NUMBER (__________) __________-__________
ADDRESS_________________________________________________IMMEDIATE SUPERVISOR _____________________________
POSITION HELD FROM ________TO ________ PAY OR SALARY START FINAL_____
WERE YOU SUBJECT TO THE FMCSRS †WHILE EMPLOYED? YES NO
WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO
THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
POSITION RESPONSIBILITIES AND DUTIES:
_________________________________________________________________________
REASON FOR LEAVING (BE SPECIFIC): ____________________________________________________________________________
PLEASE EXPLAIN ANY GAPS OF EMPLOYMENT OVER 2 WEEKS __________________________________________________
EMPLOYER NAME______________________________________ PHONE NUMBER (__________) __________-__________
ADDRESS_________________________________________________IMMEDIATE SUPERVISOR _____________________________
POSITION HELD FROM ________TO ________ PAY OR SALARY START FINAL ____________
WERE YOU SUBJECT TO THE FMCSRS† WHILE EMPLOYED? YES NO
WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO
THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
POSITION RESPONSIBILITIES AND DUTIES:
_________________________________________________________________________
REASON FOR LEAVING (BE SPECIFIC): __________________________________________________
PLEASE EXPLAIN ANY GAPS OF EMPLOYMENT OVER 2 WEEKS __________________________________________________
† THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS (FMCSRS) APPLY TO ANYONE OPERATING A MOTOR VEHICLE ON A
HIGHWAY IN INTERSTATE COMMERCE TO TRANSPORT PASSENGERS OR PROPERTY WHEN THE VEHICLE: (1) WEIGHS OR HAS A GVWR
OF 10,001 LBS. OR MORE, (2) IS DESIGNED OR USED TO TRANSPORT MORE THAN 8 PASSENGERS (INCLUDING DRIVER) OR (3) IS OF ANY
SIZE AND IS USED TO TRANSPORT HAZARDOUS MATERIALS IN A QUANTITY REQUIRING PLACARDING.
HAVE YOU EVER BEEN DISCHARGED INVOLUNTARILY FROM ANY JOB? IF SO, PLEASE EXPLAIN. ______________________________
________________________________________________________________________________________________________________________
EDUCATION
CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 9 HIGH SCHOOL 10 11 12
COLLEGE/BUSINESS/TRADE 1 2 3 4 LAST SCHOOL ATTENDED: LANGUAGES SPOKEN _________________
LIST ANY SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER: ___________________________________________
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM? ____________________________________________________
Rev. 04/03/2007
DRIVING/TRANSPORTATION EXPERIENCE
LIST STATES OPERATED IN FOR THE LAST FIVE (5) YEARS: ___________________________________________________________
ACCIDENT RECORD FOR THE PAST 3 OF MORE (USE BACK OF THIS PAGE IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
DATES NATURE OF ACCIDENT FATALITIES INJURIES HAZARDOUS
(HEAD-ON, REAR-END, ETC.) MATERIAL SPILL
LAST ACCIDENT :
NEXT PREVIOUS:
NEXT PREVIOUS:
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
LOCATION` DATE CHARGE PENALTY
IF MORE SPACE IS NEEDED USE THE BACK OF THE SHEET
DRIVER-EXPERIENCE AND QUALIFICATIONS
LIST ALL DRIVERS LICENSES OR PERMITS HELD IN THE LAST 3 YEARS
STATE LICENSE NUMBER TYPE EXPIRATION DATE
DRIVER
LICENSE
1) HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE? YES _____ NO
2) HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED? YES NO
IF THE ANSWER TO QUESTION’S 1 OR 2 IS YES, GIVE DETAILS:
__________________________________________________________________________________________
__________________________________________________________________________________________
CLASS OF EQUIPMENT CIRCLE TYPE OF DATES APPROX. # OF
EQUIPMENT FROM (M/Y) TO (M/Y) MILES (TOTAL)
STRAIGHT TRUCK □ YES □ NO VAN, TANK, FLAT , DUMP, REFER
TRACTOR AND SEMI-TRAILER □ YES □ NO VAN, TANK, FLAT , DUMP, REFER
TRACTOR –TWO TRAILERS □ YES □ NO VAN, TANK, FLAT , DUMP, REFER
TRACTOR-THREE TRAILERS □ YES □ NO VAN, TANK, FLAT , DUMP, REFER
MOTOR COACH- SCHOOL BUS □ YES □ NO 8 OR MORE PASGRS. VAN, TANK, FLAT , DUMP, REFER
MOTOR COACH –SCHOOL BUS □ YES □ NO 15 OR MORE PASGRS. VAN, TANK, FLAT , DUMP, REFER
OTHER
TO BE READ AND SIGNED BY ALL APPLICANTS
HAVE YOU EVER BEEN CONVICTED OF A CRIME OR PLED NO CONTEST TO ANY CRIMINAL OFFENSE? ___YES ____NO IF YES,
EXPLAIN THE NUMBER OF CONVICTION(S), NATURE OF OFFENSE(S) , DATES OF OFFENSE(S) WAS /WERE COMMITTED,
SENTENCE(S),IMPOSED AND TYPES OF REHABILITATION:____________________________________________________________
__________________________________________________________________________________________________________
NOTE: A YES RESPONSE DOES NOT AUTOMATICALLY DISQUALIFY YOUR APPLICATION
Rev. 04/03/2007
TO BE READ AND SIGNED BY THE APPLICANT
I UNDERSTAND THAT INFORMATION I PROVIDE REGARDING CURRENT AND/OR PREVIOUS EMPLOYERS MAY BE USED, AND THOSE
EMPLOYER(S) WILL BE CONTACTED, FOR THE PURPOSE OF INVESTIGATING MY SAFETY PERFORMANCE HISTORY AS REQUIRED BY 49
CFR 391.23(D) AND (E). I UNDERSTAND THAT I HAVE THE RIGHT TO:
• REVIEW THE INFORMATION PROVIDED BY PREVIOUS EMPLOYERS;
• HAVE ERRORS IN THE INFORMATION CORRECTED BY PREVIOUS EMPLOYERS AND FOR THOSE PREVIOUS EMPLOYERS TO RE-
SEND THE CORRECTED INFORMATION TO THE PROSPECTIVE EMPLOYER; AND
• HAVE A REBUTTAL STATEMENT ATTACHED TO THE ALLEGED ERRONEOUS INFORMATION, IF THE PREVIOUS EMPLOYER(S)
AND I CANNOT AGREE ON THE ACCURACY OF THE INFORMATION.
In exchange for the consideration of my job application by Triple B Corp (hereinafter called the Company), I agree that:
I further certify that I am not engaged in any outside activity or business that could be considered in conflict with
Company’s interest or those of its customers nor will I become engaged in such activity or business if employed.
If employed, I further agree that if Company advances any paid leave before it accrues, or advances or loans me any
money during the course of my employment, or if I lose, damage, or fail to return any company property, the company is
authorized to deduct from my wages sufficient funds to repay such loans or advances or to replace its property.
Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in
the position applied for or any other position, shall serve to create an actual or implied contract of employment , or to
confer any right to remain an employee of Triple B Corp, or otherwise to change in any respect the employment-at-will
relationship between it and the undersigned, and that relationship cannot be altered except by written instrument signed
by an Officer of the Company. Both the undersigned and Triple B Corp may end the employment relationship at any
time with or without notice and for any reason. If employed, I understand that the Company may unilaterally change or
revise their benefits, policies, and procedures and such changes may include a reduction in benefits.
I certify that the information given by me to the Company is true and complete to the best of my knowledge. I authorize
investigations of all statements contained in this application. I understand that the misrepresentation or omission of facts
called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to
contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company
from any liability as a result of such contact.
I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as
testing after employment; (2) consent to and compliance with such policy is a condition of employment; and (3) continued
employment is based on successful passing of testing under such policy.
I understand that, in connection with the routine processing of my employment application, the Company may request
from a consumer reporting agency an investigative consumer report including information as to my credit records,
character, and general reputation. Upon written request from me, the Company, will provide me with additional
information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting
Act.
______________________________________________________________________ ____________________________
APPLICANT’S SIGNATURE TODAY’S DATE
THANK YOU FOR COMPLETING THIS APPLICATION AND YOUR INTEREST IN OUR BUSINESS
Rev. 04/03/2007
APPLICANT EEO or AFFIRMATIVE ACTION INFORMATION
It is the policy of this organization to provide equal employment opportunity to all qualified applicants for
employment without regard to race, color, religion, national origin, sex, age, veteran status or disability. Various
agencies of the government require employers to invite applicants to identify themselves as indicated below.
COMPLETION OF THIS FORM IS VOLUNTARY AND IN NO WAY AFFECTS THE DECISION REGARDING
YOUR APPLICATION FOR EMPLOYMENT. THIS FORM IS CONFIDENTIAL AND WILL BE MAINTAINED
SEPARATELY FROM YOUR APPLICATION FORM.
PLEASE PRINT
Name: Date:
LAST FIRST MIDDLE
Position Applied for: (List only one)
What is your race/ethnic origin? What is your sex?
White Male
Hispanic Female
American Indian/Alaskan Native
Black or African American
Native Hawaiian or other Pacific Islander
Asian
Two or more races
Rev. 04/03/2007
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