Form 1 of 9

APPLICATION FOR EMPLOYMENT

DRIVER'S APPLICATION

RESUMES ARE NOT ACCEPTED IN LIEU OF A COMPLETED APPLICATION

  ROLLET BROS. TRUCKING CO., INC   DATE   
  227 HIGHWAY M.   P.O BOX 31
 PHONE:
 (573) 547-2573
  PERRYVILLE MISSOURI 63775
 FAX:  (573) 547-2574
   
   
 
     
POSITION APPLIED FOR:
 
 Last Name
First Name
 Middle Name
PHONE:

ADDRESS:
  Street City

 State

Zip

*DATE OF BIRTH:


*SOCIAL SECURITY:

   
 
 ADDRESS(ES) FOR THE PAST THREE YEARS:
         
 Street  City  State  Zip  How Long
         
Street
 City  State  Zip  How Long
         
 Street  City  State  Zip  How Long
         
* The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.
 
 EXPERIENCE & QUALIFICATIONS - Driver
DRIVER'S LICENSE(S):

     
  State   License No.
  Type   Expiration Date
       
  State
  License No.
  Type
  Expiration Date
       
  State
  License No.
  Type
  Expiration Date
       
       
 A. Do you currently hold more than one valid driver's license?
 B. Have you ever been denied a driver's license, permit, or privilege to operate a motor vehicle?  
 C. Has your driver's license, permit or privilege ever been suspended or revoked?  
 D. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?   
 If you answered "yes" to any of the above questions, please give details.  
 
 Have you ever been convicted or pled guilty to a felony?  
 If you answered 'yes`, when?  
 Please state the place of the conviction and the crime involved:  
 
 A conviction record will not necessarily ban you from employment. Factors such as age, time of the offense. seriousness, and nature of violation will be taken into account
 
EDUCATION
Are you a high school graduate or do you have an equivalency GED certificate?
If so, please state the name of the high school that you graduated from.

Did you attend college?
If "yes", please state the following:  
College Name:
College Address:
Total Completed Hours:
Major Degree Earned:
 
DRIVING EXPERIENCE
Class of Equipment Type of Equipment
(Van/Truck/Flat/etc)

From (Date)
To (Date)
Approximate No.
of Miles

 
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE
Date
Nature of Accident (Rear-end / upset/ etc.)
Fatalities Injuries
 
TRAFFIC CONVICTIONS FOR PAST 3 YEARS (other than parking violations)
Location Date Charge Penalty
 
As a prospective employer. we must ask any applicant for a driving position with our company whether he/she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the applicant applied for, but did not obtain, 'safety-sensitive transportation work" (driving a commercial motor vehicle) during the past three years.
   
 
Yes, I have tested positive for drugs/alcohol, or refused to take a pre-employment drug alcohol test in the three years preceding the date of this application,
No, I have not tested positive for drugs/alcohol, or refused to take a pre-employment
drug/alcohol test in the three years preceding the date of this application.
   
DOT regulations prohibit our utilizing you to perform a "safety-sensitive function" (driving a commercial motor vehicle) if you had a positive test, or a refusal to test, until and unless you provide documents showing successful completion of the return-to-duty process in accordance with DOT regulations.
 
REFERENCES:
Name Address
Phone No.

   
 
 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. I UNDERSTAND THAT MY EMPLOYMENT MAY BE IMMEDIATELY TERMINATED IF IT IS LATER LEARNED THAT ANY ENTRY ON THIS APPLICATION IS UNTRUE OR INCOMPLETE.
 
sign here

Applicant's Signature


 Today's Date

 
Various federal and state laws prohibit discrimination based on race, color, sex, religion, national origin, ancestry. age, disability, or marital status. Your response to any question on this application will not be used as a basis for unlawful discrimination.