APPLICANT NAME*
STREET ADDRESS*
CITY*
STATE*
ZIP*
PHONE 1*
PHONE 1 TYPE* ---HOMECELLOTHER
PHONE 2
PHONE 2 TYPE ---HOMECELLOTHER
EMAIL
POSITIONS APPLIED FOR*
IF HIRED, CAN YOU FURNISH PROOF YOU ARE LEGALLY ELIGIBLE TO WORK IN THE U.S?* YESNO
ARE YOU AGE 18 OR OLDER?* YESNO
ARE YOU CURRENTLY EMPLOYED?* YESNO
HAVE YOU WORKED FOR THIS COMPANY BEFORE?* YESNO
DATES: FROM
DATES: TO
POSITION
REASON FOR LEAVING
REFERRED BY
RATE OF PAY EXPECTED ($)
RATE OF PAY EXPECTED (RATE)---per hourper day
HAVE YOU EVER BEEN CONVICTED OF A FELONY?* YESNO
IF SO, WHEN & WHERE
IF YES, PLEASE EXPLAIN IN DETAIL (CONVICTION OF A FELONY IS NOT AN AUTOMATIC DISQUALIFICATION TO EMPLOYMENT - ALL CIRCUMSTANCES WILL BE CONSIDERED.):
NAME
NUMBER OF YEARS COMPLETED/CREDITS COMPLETED
DIPLOMA/DEGREE/CERTIFICATE
MAJOR/MINOR
PROGRAM
RANK
EMPLOYER
ADDRESS
CITY
STATE
ZIP
CONTACT PERSON
PHONE NUMBER
WERE YOU SUBJECT TO THE FMCSRs≠ WHILE EMPLOYED?YESNO
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?YESNO
DATE: FROM (Mo./Yr.)
DATE: TO (Mo./Yr.)
POSITION HELD
SALARY/WAGE
FOR PAST 3 YEARS OR MORE
COMPLETE ONLY IF APPLYING TO DRIVE OR REPAIR/SERVICE COMMERCIAL VEHICLES
NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC)
DATE
FATALITIES?YESNO
INJURIES?YESNO
HAZARDOUS MATERIAL SPILL?YESNO
IF YOU ANSWERED YES TO ANY ACCIDENT QUESTIONS, PLEASE EXPLAIN
AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
IF NONE, WRITE "NONE"
LOCATION
CHARGE
PENALTY
LIST ALL DRIVER LICENSES OR PERMITS HELF IN THE PAST 3 YEARS
LICENSE NO.
TYPE
EXPIRATION DATE
HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT, OR PRIVILEGE TO OPERATE A MOTOR VEHICLE?YESNO
HAS ANY LICENSE, PERMIT, OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED?*YESNO
IF THE ANSWER TO EITHER IS YES, GIVE DETAILS
CLASS OF EQUIPMENT---STRAIGHT TRUCKTRACTOR & SEMI-TRAILERTRACTOR - 2 TRAILERSTRACTOR - 3 TRAILERSMOTOR COACH/SCHOOL BUSOTHER
TYPE OF EQUIPMENT---VANTANKFLATDUMPREFER
DATES: FROM (Mo./Yr.)
DATES: TO (Mo./Yr.)
APPROX. NUMBER OF MILES
LIST STATES OPERATED IN FOR THE LAST FIVE YEARS
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER OR MECHANIC
SUMMARIZE ANY TRUCKING, TRANSPORTATION, SPECIAL EQUIPMENT, TECHNICAL, OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY.
HAVE YOU EVER TESTED POSITIVE, OR REFUSED TO TEST, ON ANY PRE-EMPLOYMENT DRUG OR ALCOHOL TEST ADMINISTERED BY AN EMPLOYER TO WHICH YOU APPLIED FOR, BUT DIDN'T OBTAIN, SAFETY-SENSITIVE TRANSPORTATION WORK COVERED BU DOT AGENCY DRUG AND ALCOHOL TESTING RULES DRURING THE PAST TWO YEARS?*YESNO
IF YOU ANSWERED YES, CAN YOU PROVIDE OR OBTAIN PROOF THAT YOU'VE SUCCESSFULLY COMPLETED THE DOT RETURN-TO-DUTY REQUIREMENTS?*YESNO
PART 382 CONTROLLED SUBSTANCES AND ALCOHOL USE TESTING APPLIES TO CDL DRIVES OF THIS COMPANY; TESTS WILL BE ADMINISTERED IN COMPLIANCE WITH THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS.
§382.113 REQUIREMENT FOR NOTICE - BEFORE PERFORMING AN ALCOHOL OR CONTROLLED SUBSTANCES TEST UNDER THIS PART, EACH EMPLOYER SHALL NOTIFY A DRIVER THAT THE ALCOHOL OR CONTROLLED SUBSTANCES TEST IS REQUIRED BY THIS PART. NO EMPLOYER SHALL FALSELY REPRESENT THAT A TEST IS ADMINISTERED UNDER THIS PART.
I authorize Rohrer's Incorporated, its agents, employees, or representatives to make such investigations of my employment, education, financial, driving, and/or other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, licensing authorities, and other persons, corporations, or organizations from all liability to inquiries and releasing truthful information, in a lawful manner, in connection with my application.
I certify that all information I have provided in order to apply for and secure work with Rohrer’s Incorporated is true, complete, and correct. I understand that any false, misleading, or omitted information in my application or interview(s) may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I understand, also, that I am required to abide by all rules and regulations of the Company.
I understand that if I am extended an offer of employment, it may be conditioned upon my successfully passing a pre-employment physical and/or drug and/or alcohol screen examination. I hereby consent to both pre- and/or post-employment physical and drug and/or alcohol screen exams as a condition of employment, if required. Federal Motor Carrier Regulations Part 282 Controlled Substances and Alcohol Use Testing applies to CDL drivers of this company; tests will be administered in compliance with the Federal Motor Carrier Safety Regulations.
I understand this application or subsequent employment does not create a contract of employment nore guaranteed employment for any definite period of time. if employed, I understand that employment is on an at-will basis, and this means that Rohere’s Incorporated or I can terminate the relationship, at any time, with or without cause and/or notice.
For commercial drivers/mechanics: I understand that information I provide regarding current and/or previous employers will be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand I have the right to:
Review information provided by previous employers; Have errors in the information corrected by previous employers to re-send the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
I have read, understand and by my checking the box, I agree to the above statements* YES
DATE*
EMAIL ADDRESS*
