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.