Andale Ready Mix Central, Inc.
3170 N. Ohio	3170 N. Ohio – Wichita, KS 67219

Employment Application

Applicant Information

Full Name:	Date:
Last	First	M.I.

Address:
Street Address	Apartment/Unit #

City	State	ZIP Code

Phone:	Email

Date Available:	Social Security No.:	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?

Have you ever been convicted of a felony?	YES	NO

If yes, explain:

Education

High School:	Address:

From:	To:	Did you graduate?	YES	NO	Diploma::

College:	Address:

From:	To:	Did you graduate?	YES	NO	Degree:

Other:	Address:

From:	To:	Did you graduate?	YES	NO	Degree:

References

Please list three professional references.

Full Name:	Relationship:
Company:	Phone:
Address:
Full Name:	Relationship:
Company:	Phone:
Address:
Full Name:	Relationship:
Company:	Phone:
Address:

Previous Employment

Company:	Phone:
Address:	Supervisor:

Job Title:	Starting Salary:	$	Ending Salary:	$

Responsibilities:

From:	To:	Reason for Leaving:

May we contact your previous supervisor for a reference?	YES	NO	Subject to FMCSA regulations? _____

Company:	Phone:
Address:	Supervisor:

Job Title:	Starting Salary:	$	Ending Salary:	$

Responsibilities:

From:	To:	Reason for Leaving:

May we contact your previous supervisor for a reference?	YES	NO	Subject to FMCSA regulations? _____

Company:	Phone:
Address:	Supervisor:

Job Title:	Starting Salary:	$	Ending Salary:	$

Responsibilities:

From:	To:	Reason for Leaving:

May we contact your previous supervisor for a reference?	YES	NO	Subject to FMCSA regulations? ____

License Information

State of License:	License Number:

Expiration Class: ___ A ___ B ___ C

Driving Experience

Class of Equipment	Type of Equipment (Can, Tank, Flat, Etc.)	Dates From To
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: