Employment Application

The purpose of this application is to qualify applicant and/or determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and A-1 Pump & Jet Services, Inc.

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Comments

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Applicant Information

Date

Position Applying For:*

General Labor

Driver

Administrative

Name:*

First Middle Last

Address:*

Street Address City State ZIP

How long have you lived at this address?*

Less than 3 years

3 years or more

List previous addresses for the past three years. Click the red plus sign to add additional addresses if needed.*

Street Address, City, State, & Zip

From

Phone:*

Emergency Phone Number:*

Email:*

Age*

The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

Date of Birth*

DOT Physical Exam Expiration Date:

Have you ever worked for this company?*

Yes

If yes, when?*

Reason for leaving:*

Education History

Choose the highest level of education completed:*

Previous Employment

Give a complete record of all employment for the past FIVE years, starting with the most recent, including any unemployment or self employment. Click the ADD EMPLOYER BUTTON below to add as many employers as needed.

Employer Name	Position Held	From (Month/Year)	To (Month/Year)	Actions

There are no Employers.

Work Experience

List states operated in as a CDL Driver, for the last five years:

Have you ever operated any of the equipment listed below?*

Straight Truck

Tractor and Semi-Trailer

Tractor 100+ hp

Loader, Bobcat, etc

Other

None of these

Please describe how many years of experience you have with the above equipment and the industry you operated in (ie, farming, construction, etc)

List any job related skills not previously mentioned:

List any administrative courses/training completed (Microsoft Office, QuickBooks, etc):

List your vehicle accident record for past three years (personal and commercial). Click the red plus sign to add additional accident records if needed.

Date of Accident

Nature of Accident (Head on, upset, etc)

Location of Accident

# of Fatalities

# of Injured People

List all traffic convictions & forfeitures for the last three years (other than parking violations). Click the red plus sign to add more if needed.

Date

Location

Charge

Penalty

List all Driver's Licenses held in the past 3 years. Click the red plus sign to add more than one if needed.*

State

License #

Type

Endorsements

Expiration Date

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

Yes

Please explain:*

Has any license, permit or privilege ever been suspended or revoked?*

Yes

Please explain:*

Is there any reason you might be unable to perform the functions of the job for which you have applied?*

Yes

Please explain:*

Have you ever been convicted of a felony?*

Yes

Please explain:*

References

List three persons for references, other than family members, who have knowledge of your safety habits:

Reference Name

Reference Phone

Reference Email

Acknowledgement

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

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.

Acknowledgment*

By checking this box, I certify that I have read and agree to all the above statements.

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Applicant Name

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Date

Employment Application

Applicant Information

Education History

Previous Employment

Work Experience

References

Acknowledgement

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23

Driver Applicant Drug and Alcohol Pre-Employment Statement

Controlled Substance & Alchol Testing Information Acknowledgement/Consent Form

Seven-Day Prior Log Form

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

Acknowledgement

Emporia, Kansas

Holcomb, Kansas