DRIVER'S APPLICATION FOR EMPLOYMENT

    Applicant Name

    Date of Application

    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, veteran status, non-job related disability, or any other protected group status.

    TO BE READ AND SIGNED BY APPLICANT

    I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

    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. I understand that information I provide regarding current and/or previous employers may 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 and for those 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.

    Signature

    Date

    APPLICANT TO COMPLETE

    (Answer all questions.)

    Job Location

    Position(s) Applied For

    Name (last, first, middle)

    List your addresses of residency for the past three years.

    Current Address

    Street

    City

    State

    Zip Code

    Phone

    How Long?

    Previous Address #1

    Street

    City

    State

    Zip Code

    Phone

    How Long?

    Previous Address #2

    Street

    City

    State

    Zip Code

    Phone

    How Long?

    Do you have the legal right to work in the United States?
    YesNo

    Date Of Birth
    (Required for Commercial Drivers)

    Can you provide proof of age?
    YesNo

    Have you worked for this company before?
    YesNo

    Where?

    Dates

    From

    To

    Rate of Pay

    Position

    Reason for Leaving

    Are you now employed?
    YesNo

    If not, how long since leaving your last employment?

    Who referred you?

    Rate of Pay Expected

    Have you ever been bonded?
    YesNo

    Name of bonding company

    Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?
    YesNo

    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.)

    Employer #1

    Name

    Address

    City

    State

    Zip

    Contact Person

    Phone Number

    From

    To

    Position Held

    Salary/Wage

    Reason for Leaving

    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

    Employer #2

    Name

    Address

    City

    State

    Zip Code

    Contact Person

    Phone Number

    From

    To

    Position Held

    Salary/Wage

    Reason for Leaving

    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

    Employer #3

    Name

    Address

    City

    State

    Zip

    Contact Person

    Phone Number

    From

    To

    Position Held

    Salary/Wage

    Reason for Leaving

    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

    Employer #4

    Name

    Address

    City

    State

    Zip

    Contact Person

    Phone Number

    From

    To

    Position Held

    Salary/Wage

    Reason for Leaving

    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

    Employer #5

    Name

    Address

    City

    State

    Zip

    Contact Person

    Phone Number

    From

    To

    Position Held

    Salary/Wage

    Reason for Leaving

    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

    Employer #6

    Name

    Address

    City

    State

    Zip

    Contact Person

    Phone Number

    From

    To

    Position Held

    Salary/Wage

    Reason for Leaving

    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

    * Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

    †The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers(including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

    ACCIDENT RECORD FOR PAST 3 YEARS OR MORE

    Have you been in a vehicle accident in the last three years?
    YesNo

    If yes, please document below.

    Date

    Nature of Accident (head-on, rear-end, upset, etc.)

    Fatalities

    Injuries

    Hazardous Material Spill
    YesNo

    Date

    Nature of Accident (head-on, rear-end, upset, etc.)

    Fatalities

    Injuries

    Hazardous Material Spill
    YesNo

    Date

    Nature of Accident (head-on, rear-end, upset, etc.)

    Fatalities

    Injuries

    Hazardous Material Spill
    YesNo

    Have you been involved in more than these three vehicle accidents in the past three years?
    YesNo

    TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

    Have you been involved in any traffic convictions or forfeitures in the past three years?
    YesNo

    If yes, please document below.

    Location

    Date

    Charge

    Penalty

    Location

    Date

    Charge

    Penalty

    Location

    Date

    Charge

    Penalty

    Have you been involved in more than these three traffic convictions or forfeitures in the past three years?
    YesNo

    EXPERIENCE AND QUALIFICATIONS - DRIVER

    Driver licenses or permits held in the past 3 years

    State

    License No.

    Class

    Endorsement(s)

    Expiration Date

    State

    License No.

    Class

    Endorsement(s)

    Expiration Date

    State

    License No.

    Class

    Endorsement(s)

    Expiration Date

    A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
    YesNo

    B. Has any license, permit, or privilege ever been suspended or revoked?
    YesNo

    IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS

    DRIVING EXPERIENCE

    STRAIGHT TRUCK
    YesNo

    Type of equipment
    VanTruckFlatDumpRefer

    Dates

    Approx. No. of Miles (Total)

    TRACTOR AND SEMI-TRAILER
    YesNo

    Type of equipment
    VanTruckFlatDumpRefer

    Dates

    Approx. No. of Miles (Total)

    TRACTOR - TWO TRAILERS
    YesNo

    Type of equipment
    VanTruckFlatDumpRefer

    Dates

    Approx. No. of Miles (Total)

    TRACTOR - THREE TRAILERS
    YesNo

    Type of equipment
    VanTruckFlatDumpRefer

    Dates

    Approx. No. of Miles (Total)

    MOTORCOACH - SCHOOL BUS (More than 8 passengers.)
    YesNo

    Type of equipment
    VanTruckFlatDumpRefer

    Dates

    Approx. No. of Miles (Total)

    MOTORCOACH - SCHOOL BUS (More than 15 passengers.)
    YesNo

    Type of equipment
    VanTruckFlatDumpRefer

    Dates

    Approx. No. of Miles (Total)

    OTHER

    LIST STATES OPERATED IN FOR THE 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?

    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)

    SELECT HIGHEST GRADE COMPLETED:
    123456789101112COLLEGE: 1234

    LAST SCHOOL ATTENDED

    Name

    City

    State

    TO BE READ AND SIGNED BY APPLICANT

    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.

    Signature

    Date

    PLEASE READ CAREFULLY

    APPLICATION FORM WAIVER

    In exchange for the consideration of my job application by C.W. Roberts Contracting, Inc. (hereinafter called “the Company”), I agree that:

    Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of C.W. Roberts Contracting, Inc., or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President/General Manager of the Company. Both the undersigned and C.W. Roberts Contracting, Inc. may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include a reduction in benefits

    I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

    I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

    I certify that I have received a written notification that the Company may obtain a consumer report or reports on me. I authorize this Company to obtain such a report or reports for use in connection with my application for employment and for other employment-related reasons. If hired, this authorization shall remain on file and serve as ongoing authorization for procurement of employment-related consumer reports at any time during my employment. I understand that the term “consumer report” includes, but is not limited to, credit checks, criminal background checks, Department of Motor Vehicle reports, and investigative consumer reports. I authorize the Company to conduct electronic inquiry related to my background, including review of all social networking sites and to make adverse decisions as a result of such inquiries. I further understand that the term “investigative consumer report” means a report in which information on my character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with my neighbors, friends, or associates, or with others with whom I am acquainted or who may have knowledge concerning any such items of information.

    I further understand that my employment with the Company shall be probationary for a period of (90) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

    This Company provides equal employment opportunities to all employees and applicants without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, pregnancy, disability, or any other protected status. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

    Acknowledgment and Agreement:

    APPLICANT SIGNATURE

    DATE

    EEO SURVEY

    We consider applicants for all positions without regard to race, color, sex, national origin, religion, age, marital status, genetic information status, pregnancy, disability, veteran status, sexual orientation, gender identification, transgender, or any other legally protected class. The information requested on this form is collected by the company to comply with Affirmative Action/Equal Employment Opportunity and other federal laws and regulations. This information is considered confidential and will not be a part of your official application for employment.

    Position title for which you are applying:

    Gender:
    MaleFemale

    Date of Birth:

    Race:
    Hispanic or LatinoWhite (Not Hispanic or Latino)Black or African AmericanNative Hawaiian or Other Pacific IslanderAmerican Indian or Alaska NativeAsianTwo or More Races

    You are invited to identify yourself as a disabled veteran, veteran of the Vietnam Era, or disabled individual. This information is voluntary and will be kept confidential. Refusal to provide it will not subject you to any adverse treatment. The information will be used for affirmative action purposes. It is not used or considered in the selection process and is filed separately from the application.

    The Vietnam Era is defined by Federal Regulations as August 5, 1964 to May 7, 1975.

    Veteran Status: Which applies to you?

    Disabled Veteran: A Veteran entitled to compensation for disability rated at 30% or more, or a person who is discharged or released from active duty because of a service connected disability.Recently Separated Veteran: A Veteran who served on active duty in the U.S. military, ground, naval or air service during the three-year period beginning on the date of such veteran’s discharge or release from active duty.Active Duty Wartime or Campaign Badge Veteran: A Veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized by the Department of Defense.Armed Forces Service Medal Veteran: A Veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.I am a protected veteran, but I choose not to self identify the classifications to which I belong.I am not a protected veteran.

    To qualify as a Disabled Individual, you must:
    1. Have a physical or mental impairment which substantially limits one or more life activities (including employment);
    2. Have a record of such impairment; or
    3. Be regarded as having such impairment.

    Do you qualify as such an individual?

    YesNo

    This information is for compliance reporting only.

    It will be removed from your application prior to review.

    It is not considered in the employment process.