Employment Application

Applicant Information

First Name

Middle Name

Last Name

Date

Street Address

Apartment/Unit No.

City

State

Zip Code

Phone No.

Email

Date Available

Desired Salary

Position Applied For

Are you a citizen of the United States? Yes No

If no, are you authorized to work in the U.S.? Yes No

Have you ever worked for this company? Yes No

If yes, when?

Education

High School

Address

From

To

Did you graduate?

Yes No

Diploma

College

Address

From

To

Did you graduate?

Yes No

Degree

College

Address

From

To

Did you graduate?

Yes No

Degree

Reference

Full Name

Relationship

Company

Phone

Address

Employment

Company

Supervisor

address

Phone

Responsibilities

From

To

Reason for leaving

Desired Salary

May we contact your previous employer?

Yes No

Company

Supervisor

address

Phone

Responsibilities

From

To

Reason for leaving

Desired Salary

May we contact your previous employer?

Yes No

Company

Supervisor

address

Phone

Responsibilities

From

To

Reason for leaving

Desired Salary

May we contact your previous employer?

Yes No

License Information

State Of License

License Number

Expiration

Driving Experience

Class of Equipment	Type of Equipment (Can, Tank, Flat, Etc.)	Dates
Straight Truck
Tractor and Semi-Trailer
Tractor-Two Trailers
Other

Accident Record for Past 3 Years or More (continue on back side if more space is needed)

Dates	Nature of Accident (head-on, read-end, upset, etc.)	Nbr. Of Fatalities	Number of Injuries	Chemical Spill
				Yes No
				Yes No
				Yes No

Traffic Convictions & Forfeitures for the Past 3 Years (other than parking violations)

Dates	Nature of Accident (head-on, read-end, upset, etc.)	Nbr. Of Fatalities	Number of Injuries	Chemical Spill
				Yes No
				Yes No
				Yes No

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. I authorize you to make investigations and inquiries to my employment and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquiries and release information in connection with my application. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature

Date