APPLICANT INSTRUCTIONS

Individuals who need assistance with any phase of the application process should notify the person who gave them the application to request a reasonable accommodation.

1. Complete all fields. 2. Incomplete or illegible applications will not be processed. Please enter “Not applicable” when a question does not apply. 3. Provide only requested information. Failure to do so may result in disqualification of your application. 4. Some packets may include an EEO Self Identification Form. This information is being gathered for federal record-keeping and/or affirmative action purposes only. The information requested is voluntary and will be kept confidential. An applicant will not be subject to any adverse treatment for refusing to complete the questionnaire.

Basic Information

Position applied for*

Referred source

Name*

Email*

Home phone

Cell Phone*

Current address*

Are you at least 18 years of age?*YesNo

Are you legally eligible to work in the United States?*YesNoProof of employment eligibility will be required if hired.

AVAILABILITY

What category would you prefer?Full-timePart-time Temporary

What date can you start?

PROFESSIONAL LICENSES AND CERTIFICATIONS

Do you hold any professional licenses or certifications?* YesNo

Has your license/certification ever been revoked or suspended? YesNo

If yes, state the reason(s), date of revocation or suspension, and date of reinstatement:

REFERENCES

Include only individuals familiar with your work ability. Do not include relatives or names of supervisors listed.

REFERENCE-1

Name*Phone*Years known/Relationship*Address*

REFERENCE-2

NamePhoneYears known/RelationshipAddress

REFERENCE-3

NamePhoneYears known/RelationshipAddress

HIGH SCHOOL EDUCATION

Name

Address

Graduated

COLLEGE EDUCATION

Name

Address

Graduated

Degree Type

OTHER EDUCATION

Name

Address

Graduated

Degree Type

Previous Employment

Your application may not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical. Ask for a phone book or call information if necessary. For employers outside the U.S., a current fax number is mandatory.

Company Name*

Dates*

Supervisor Name

Job Title*

Duties:

Reason for leaving

Address

If yes, may we contact?

Are you currently working for this employer?

Were you subject to FMCSRs** while employed?

Was your job designated as a safety-sensitive function in any DOT-regulated mode to the drug and alcohol testing requirements of 49 CFR Part 40?

**Federal Motor Carrier Safety Regulations 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 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is any size vehicle used to transport hazardous material in a quantity requiring placarding.

SECOND MOST RECENT EMPLOYER

Company Name

Dates

Supervisor Name

Job Title

Duties:

Reason for leaving

Address

If yes, may we contact?

Are you currently working for this employer?

Were you subject to FMCSRs** while employed?

Was your job designated as a safety-sensitive function in any DOT-regulated mode to the drug and alcohol testing requirements of 49 CFR Part 40?

Third MOST RECENT EMPLOYER

Company Name

Dates

Supervisor Name

Job Title

Duties:

Reason for leaving

Address

If yes, may we contact?

Are you currently working for this employer?

Were you subject to FMCSRs** while employed?

Was your job designated as a safety-sensitive function in any DOT-regulated mode to the drug and alcohol testing requirements of 49 CFR Part 40?

DRIVER'S LICENSE INFORMATION

If the job requires, do you have the appropriate valid driver’s license?

License information

Have you had any moving violations within the last seven years? Please describe

CERTIFICATION AND RELEASE

I understand that this application form is intended for use in evaluating my qualifications for employment and that this application is not an offer of employment. I further understand that if hired, my employment will be considered “at-will” and that my employment may be terminated for any reason, with or without cause or notice, at any time by me or the Company and that this application is not intended to constitute a contract of continued employment.

I certify that the information submitted by me on this application is true and complete. I understand that any false information, misrepresentations or omissions on this application, on other written materials, or provided during any interviews will lead to the rejection of my application or, if I am employed, discipline up to and including termination at the time such false information or omission is discovered.I understand that additional testing of job-related skills and for the presence of drugs may be required prior to employment.

I also understand that after an offer of employment and prior to reporting to work, I may be required to submit to a medical review and depending on Company policy and the needs of the job, I may be required to complete a medical history form and be examined by a medical professional designated by the company. I also understand that i may not be under the influence of drugs or alcohol during employment and that if Company policy so requires, I may be required to submit to drug and/or alcohol testing at an approved testing facility.

I understand that smoking is prohibited in all indoor areas of the Company’s facilities unless designated smoking areas have been established at a particular location in accordance with applicable state and local law.I authorize the Company and/or its agents, including consumer reporting bureaus, to investigate and verify any of the information provided by me.

I authorize my former employers, educational institutions, references and any relevant agencies to provide information to the Company and/or its agents concerning my background and experience. i release the Company and all parties providing information to the Company about my background and experience from any liability whatsoever arising therefrom.

Signature*

Date*

Self Identification

Gender

Race / EthnicityHispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) - A person with origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachmentTwo or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above five races. Prefer not to Answer

Completion of this data is completely voluntary; however, we are required to ask if you will volunteer this information. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by Human Resources.

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Employment Application

APPLICANT INSTRUCTIONS

Basic Information

AVAILABILITY

PROFESSIONAL LICENSES AND CERTIFICATIONS

REFERENCES

REFERENCE-1

REFERENCE-2

REFERENCE-3

HIGH SCHOOL EDUCATION

COLLEGE EDUCATION

OTHER EDUCATION

Previous Employment

SECOND MOST RECENT EMPLOYER

Third MOST RECENT EMPLOYER

DRIVER'S LICENSE INFORMATION

CERTIFICATION AND RELEASE

Self Identification