Please fill out application in its entirety, incomplete forms may cause delay in processing. Do not substitute resume for application. It is our policy to provide equal employment opportunity to all qualified persons without regard toward race, age, color, sex, religion, national origin, handicap, marital status, or any other consideration made unlawful by federal, state, or local laws. Last Name First Name Middle Name Date Street City State Zip Phone Soc. Sec. No Position applied for Salary desired How did you learn of this opening? Advertisement Agency Walk-in Relative Friend Date available to start Are there any hours or days you are not available to work Are you willing to work overtime as required Yes No Are you willing to travel Yes No If your position requires driving, can you provide proof of current driver’s license, insurance and DMV Record Yes No Have you ever been employed by us before? If yes date and location. Can you, after employment, submit verification of your legal right to work in the United States Have you ever been convicted of a felony? A “yes” answer will not necessarily disqualify you Yes No If yes, describe the circumstances Education Name and Location of School High School No. Years Completed Major Diploma / Degree College/University Name and Location of School No. Years Completed Major Diploma / Degree College/University Name and Location of School No. Years Completed Major Diploma / Degree Other Training/Education Name and Location of School No. Years Completed Major Diploma / Degree In addition to your work history, what other experience, skills or qualifications would especially qualify you for the position(s) applied for DRIVING EXPERIENCE & QUALIFICATION ONLY CDL APPLICANTS NEED TO COMPLETE THIS SECTION BELOW DATE OF BIRTH (THE U.S. DEPARTMENT OF TRANSPORTATION REQUIRES THAT CDL APPLICANTS STATE THEIR DATE OF BIRTH) CAN YOU PROVIDE PROOF OF AGE OVER 18? Yes No THE U.S. DEPARTMENT OF TRANSPORTATION REQUIRES THAT ALL CDL APPLICANTS PASS CERTAIN PHYSICAL TESTS BEFORE THEY ARE HIRED TO DIRVE A MOTOR CARRIER. FMCSR § 391 SUBPART E. DATE OF LAST DEPARTMENT OF TRANSPORTATION PRESCRIBED PHYSICAL EXAMINATION LICENSES DRIVER LICENSES HELD IN PAST 3 YEARS MUST BE SHOWN STATE LICENSE NO. TYPE EXPIRATION DATE STATE LICENSE NO. TYPE EXPIRATION DATE STATE LICENSE NO. TYPE EXPIRATION DATE 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 HAVE YOU EVER BEEN DISQUALIFIED FOR VIOLATIONS OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS Yes No IF YOU ANSWERED "YES" TO A, B OR C, ATTACH STATEMENT GIVING DETAILS LIST STATES YOU OPERATED IN DURING LAST FIVE YEARS LIST SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER LIST SAFE DRIVING AWARDS, DATE AND PRESENTER OF AWARD DRIVING EXPERIENCE CLASS OF EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.) DATES (MONTH/YEAR - TO/FROM) APPROXIMAT E TOTAL CLASS OF EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.) DATES (MONTH/YEAR - TO/FROM) APPROXIMAT E TOTAL CLASS OF EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.) DATES (MONTH/YEAR - TO/FROM) APPROXIMAT E TOTAL ACCIDENT REVIEW FOR PAST 3 YEARS LAST ACCIDENT NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES NEXT PREVIOUS NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS OTHER THAN PARKING VIOLATIONS LOCATION DATE CHARGE PENALTY LOCATION DATE CHARGE PENALTY LOCATION DATE CHARGE PENALTY LIST ALL ADDRESSES FOR PAST 3 YEARS STREET CITY STATE ZIP STREET CITY STATE ZIP EMPLOYMENT HISTORY May we contact your current employer Yes No Current Employer Address Telephone Number Date Started Date Left Start Salary End Salary Start Position End Position Supervisor’s Name/Title Supervisor Phone Responsibilities Reason for Leaving Previous Employer Address Telephone Number Date Started Date Left Start Salary $ End Salary $ Start Position End Position Supervisor’s Name/Title Supervisor Phone Responsibilities Reason for Leaving Previous Employer Address Telephone Number Date Started Date Left Start Salary $ End Salary $ Start Position End Position Supervisor’s Name/Title Supervisor Phone Responsibilities Reason for Leaving Professional References: Name Company/Address Phone Number Relationship # of Years Known Name Company/Address Phone Number Relationship # of Years Known Name Company/Address Phone Number Relationship # of Years Known APPLICANT’S CERTIFICATION AND AGREEMENT I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand false statements on this Application will result in immediate dismissal or removal of my Application from consideration. I authorize the Company to investigate all statements contained in this Application and to secure information about my experience with former employers, education institutions and agencies, and for those parties to provide information concerning my experience, releasing all parties from any liability arising therefrom. I understand that employment at the Company is “at will,” which means that either I or the Company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by law. All employment is continued on that basis. I understand that no supervisor, manager or executive of the Company, other than the President, has any authority to alter the foregoing and then only in writing. If I am employed by the Company, and my employment is terminated and I believe the termination was wrongful and/or violated any of my rights, I and the Company agree to submit any dispute arising out of the termination of my employment exclusively to final and binding arbitration before a neutral arbitrator and not to any court. I and the Company also agree that any claim by me of unlawful harassment or discrimination allegedly occurring in the course of my employment with the Company which cannot be resolved by the Company’s internal process and/or with the administrative assistance of the California Department of Fair Employment and Housing (“DFEH”) or the Equal Employment Opportunity Commission (“EEOC”) will be submitted exclusively to final and binding arbitration and not to any other forum. If I decide to dispute my termination, I agree to deliver a written request for arbitration to the Company within the time limits which would apply to the filing of a civil complaint in court. If the Company does not receive a written request for arbitration from me within the time limits which would apply to the filing of a civil complaint in court, I agree I will have waived any right to raise any claims arising out of the termination of my employment at the Company in arbitration or in any court or other forum. If I and the Company are unable to agree upon a neutral arbitrator, the Company will obtain a list of five (5) arbitrators from a state or federal arbitration service. I (first) and then the Company will alternately strike names from the list until only one name remains; the remaining person shall be the arbitrator. The arbitrator shall be bound by the qualifications and disclosure provisions of the 1989 Model Employment Arbitration Procedures of the American Arbitration Association and shall order such discovery as is appropriate to nature of the claim. The arbitrators shall have the authority to order any legal and equitable remedy, including costs and attorney’s fees as appropriate, which would be available in a civil or administrative action on the claim. Arbitration proceedings shall be held in the city or town where my employment services were performed, at the Company headquarters, or at any other location mutually agreed upon by me and the Company. I and the Company agree that if any court of competent jurisdiction declares that any part of this arbitration agreement is illegal, invalid, or unenforceable, such a declaration will not affect the legality, validity, or enforceability of the remaining parts of this agreement and the illegal, invalid, or unenforceable part will no longer be part of this agreement. The provisions of this arbitration agreement shall survive the termination of my employment and any other agreement associated therewith and shall remain in full force and effect thereafter. THIS APPLICATION CONTAINS A WAIVER OF YOUR RIGHT TO A TRIAL BY COURT OR JURY IN A DISPUTED TERMINATION AND/OR FOR CLAIMS OF UNLAWFUL HARASSMENT OR DISCRIMINATION ALLEGEDLY OCCURRING DURING THE COURSE OF EMPLOYMENT. Your Initials: