Employment application

DRIVER’S APPLICATION FOR EMPLOYMENT
STRUPP TRUCKING, INC./ STRUPP EXCAVATING/ALWAYS REDI-MIX
N6200 CTY HWY XX-ONALASKA, WI Phone: (608)781-9828 Fax: (608)781-1789
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to
race, color, religion, sex, national origin, age, marital status or non-job related disability.
Position(s) Applied For __________________________________________ Date of Application ______________________
Name _______________________________________________________ Social Security Number ____________________
Last First Middle
List your addresses of residency for the past 3 years
Current Address: ______________________________________________________ How Long? ____________
Street
_________________________________________________ Phone _____________________
City State & Zip Code
Previous Addresses:_____________________________________________ How Long? ____________
Street
_________________________________________________
City State & Zip Code
_______________________________________________________________ How Long? ____________
Street
_________________________________________________
City State & Zip Code
Do you have the legal right to work in the United States? _______________
Date of Birth ______ / ______ / ______ Can you provide proof of age? ______________
(Required for Commercial Drivers)
Have you worked for this company before? ______________ Where? _________________________________
Are you now employed? __________ If not, how long since leaving last employment? ____________________
Who referred you? _________________________________________ Rate of pay expected ______________
Have you ever been convicted of a felony? ______________________________________________________
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all
circumstances will be considered.
—————————————————————————————————————————————————————–
Is there any reason you might be unable to perform the functions of the job for which you have applied
(as described in the attached job description)? _________
If yes, explain if you wish.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employers during
the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle.
(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
EMPLOYER NAME:
DATES EMPLOYED:
ADDRESS:
FROM:
TO:
CITY:
POSITION HELD:
CONTACT PERSON:
SALARY/WAGE:
Number of Accidents: States Driven In:
Reason for Leaving:
Did you drive a vehicle requiring a CDL? YES NO
EMPLOYER NAME:
DATES EMPLOYED:
ADDRESS:
FROM:
TO:
CITY:
POSITION HELD:
CONTACT PERSON:
SALARY/WAGE:
Number of Accidents: States Driven In:
Reason for Leaving:
Did you drive a vehicle requiring a CDL? YES NO
EMPLOYER NAME:
DATES EMPLOYED:
ADDRESS:
FROM:
TO:
CITY:
POSITION HELD:
CONTACT PERSON:
SALARY/WAGE:
Number of Accidents: States Driven In:
Reason for Leaving:
Did you drive a vehicle requiring a CDL? YES NO
* Includes vehicles having a GVWR of 26,0001 lbs. Or more, vehicles designed to transport 15 or more passengers, or any size vehicle used
to transport hazardous materials in a quantity requiring placarding.
EDUCATION
CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4
LAST SCHOOL ATTENDED ____________________________________________________________
(NAME) (CITY / STATE)
EXPERIENCE AND QUALIFICATIONS – DRIVER
STATE LICENSE NO. TYPE EXPIRATION DATE
DRIVER
LICENSE
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, GIVE DETAILS _____________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
DRIVING EXPERIENCE IF NONE, WRITE NONE
CLASS OF EQUIPMENT TYPE OF EQUIPMENT DATES APPROX. NO. OF MILES
(VAN, TANK, FLAT, ETC) FROM TO
STRAIGHT TRUCK
TRACTOR AND SEMI-TRAILER
TRACTOR – TWO TRAILERS
MOTOR COACH – SCHOOL BUS
OTHER
LIST STATES OPERATED IN FOR LAST FIVE YEARS: ______________________________________________________
______________________________________________________________________________________________________
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER: _____________________________
_____________________________________________________________________________________________________
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM? _____________________________________
_____________________________________________________________________________________________________
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
DATES NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC) FATALITIES INJURIES
LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
LOCATION DATE CHARGE PENALTY
PHYSICAL HISTORY
FEDERAL MOTOR CARRIER SAFETY REGULATIONS SECTION 391.41 provides that a person shall not drive a motor vehicle unless that
person is physically qualified to do so. It is an essential function of an over-the-road driver to satisfy the DOT qualifications. Please answer Yes or
No to the following questions.
Below is a list of questions that will be asked on the mandatory Department of Transportation Physical Examination Form.
Have you ever received professional help for:
YES NO Date YES NO Date
Heart ______ ______ ___________ High Blood Pressure ______ ______ ____________
Hernia ______ ______ ____________ Cardiovascular Disease ______ ______ ____________
Physical Disorders ______ ______ ____________ Diabetes ______ ______ ____________
Seizures Any Other Nervous
Convulsion or Fainting ______ ______ ____________ Disorders ______ ______ ____________
If any answer to any question above is “Yes”, please explain in detail ________________________________________
________________________________________________________________________________________________________________________
Vision – Do you have at least 20/40 (Snellen) with or without corrective lenses on both eyes? Yes ______ No ______
List all current medications being taken ________________________________________________________________
________________________________________________________________________________________________________________________
Do you use, or have you ever used, amphetamines, narcotics, marijuana, or any other habit forming drug or controlled
Substance? If yes, when. ___________________________________________________________________________
________________________________________________________________________________________________________________________
Time lost from work in the past three years? ____________________________________________________________
Can you perform the following essential job functions with or without reasonable accommodation:
Pull 5th wheel pin with an average of 200 lbs. Force? Yes ____ No ____
Pull yourself into a tractor at 60% of your body weight? Yes ____ No ____
Lift up to a maximum of 70 lbs? Yes ____ No ____
Adequately enter & exit a trailer from ground level without assistance? Yes ____ No ____
Service and grease truck from underside? Yes ____ No ____
EXPERIENCE AND QUALIFICATIONS – OTHER
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
_________________________________________________________________________________
_________________________________________________________________________________
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
_________________________________________________________________________________
_________________________________________________________________________________
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)
_________________________________________________________________________________
TO BE READ AND SIGNED BY APPLICANT
Per FMCSR 391.21(d) Before an application is submitted, the motor carrier shall inform the applicant that the information he/she
provides for the employment history may be used, and the applicant’s prior employers may be contacted, for the purpose of
investigating the applicant’s safety performance history information. The prospective employer must also notify the driver in writing
of his/her due process rights as specified in 391.23(i) regarding information received as a result of these investigations. You the
applicant have the following rights: (i) The right to review information provided by previous employers; (ii) The rights to have errors
in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the
prospective employer; (iii) The right to have a rebuttal statement attached to the alleged erroneous information, if the previous
employer and the driver cannot agree on the accuracy of the information.
I understand that the information in this application will be used for investigation as required by 391.23. This certifies that this
application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may
result in discharge. I understand also, that I am required to abide by all rules and regulations of the Company.
_________________ ____________________________
Date Applicant’s Signature