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Tipton Trucking, Inc. - Employment Application

DRIVER'S APPLICATION FOR EMPLOYMENT

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Applicant's Last Name
Applicant's First Name
Middle Initial
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 that 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.
* Applicant's Signature
Date
*By printing name and initialing, you agree this is an equivalent to a written signature.
APPLICANT TO COMPLETE

Position(s) Applied for

Name (first, middle, last)
Social Security #

List your addresses of residency for the past 3 years.

Current Address
Street
City
State
Zip
Phone
How long?
Previous Addresses
Street
City
State
Zip
Phone
How long?
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Street
City
State
Zip
Phone
How long?
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Street
City
State
Zip
Phone
How long?
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Do you have the legal right to work in the United States?

Date of Birth (required for Commercial Drivers)

Can you provide proof of age?
Have you worked for this company before?
If yes, where?
Dates: From
To
Rate of Pay
Position
Reason for Leaving
Are you Employed?
If not, how long since leaving last employment?
Who referred you?
Rate of pay expected

Have you ever been bonded?
(Answer only if a job requirement)

Name of Bonding Company
Have you ever been convicted of a felony?
If yes, please explain fully in the space provided. Conviction of a crime in not an automatic bar to employment- all circumstances will be considered.
Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]?

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 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. Attach an additional file upon submission of application if necessary.)

Employer Name
Dates you worked (from - to)
Position Held
Salary/Wage
Reason for Leaving
Address
City
State
Zip
Contact Person
Phone
WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?
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?
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Employer Name
Dates you worked (from - to)
Position Held
Salary/Wage
Reason for Leaving
Address
City
State
Zip
Contact Person
Phone
WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?
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?
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Employer Name
Dates you worked (from - to)
Position Held
Salary/Wage
Reason for Leaving
Address
City
State
Zip
Contact Person
Phone
WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?
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?
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Employer Name
Dates you worked (from - to)
Position Held
Salary/Wage
Reason for Leaving
Address
City
State
Zip
Contact Person
Phone
WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?
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?
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Employer Name
Dates you worked (from - to)
Position Held
Salary/Wage
Reason for Leaving
Address
City
State
Zip
Contact Person
Phone
WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?
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?

*Includes vehicles having a GVWR of 26,001 lobs. 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 more than 8 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
IF NONE, WRITE "NONE".
DATES
NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)
FATALITIES
INJURIES

HAZARDOUS MATERIAL SPILL

TRAFFIC CONVICTIONS AND FORFEITURES
FOR THE PAST 3 YEARS

(OTHER THAN PARKING VIOLATIONS). IF NONE, WRITE "NONE".
LOCATION
DATE
CHARGE
PENALTY
EXPERIENCE AND QUALIFICATIONS - DRIVER
List all driver licenses or permits held in the past three years
STATE
LICENSE NO.
TYPE
EXP. DATE
A. Have you ever been denied a license or permit or priviledge to operate a motor vehicle?
B. Has any license, permit or priviledge even been suspended or revoked?
IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS:
DRIVING EXPERIENCE
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT
DATES
(FROM - TO)
APPROX. NO.
OF MILES (TOTAL)
Straight Truck

Van Tank
Flat Dump
Refer
Tractor & Semi-Trailer

Van Tank
Flat Dump
Refer
Tractor - Two Trailers

Van Tank
Flat Dump
Refer
Tractor - Three Trailers

Van Tank
Flat Dump
Refer
Motorcoach - School Bus
(More than 8 passengers)

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Motorcoach - School Bus
(More than 15 passengers)

-------------------
Other
LIST STATES OPERATED IN FOR 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):
EDUCATION
CHECK HIGHEST GRADE COMPLETED
GRADE SCHOOL:
HIGH SCHOOL:
COLLEGE:
LAST SCHOOL ATTENDED NAME: CITY: STATE:
PREVIOUS EMPLOYER & DRUG TEST INFORMATION

I a uthorize you to release to the below listed prospective employer information concerning my Alcohol and Controlled Substances Testing done while employed by you and that you obtained from previous requests for information.

Tipton Trucking, Inc.
397 Waterway Road
Oxford, PA 19063
Phone: 610-932-5120
Fax: 610-932-3328

Full Name: Social Security #:
Signature: Date:
REQUEST FOR INFORMATION
I hereby authorize you to release the following information to Tipton Trucking, Inc. for the purposes of investigation as request by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability that may result from furnishing such information.
Date: Signature:
MOTOR VEHICLE RECORD RELEASE & AUTHORIZATION FORM

TO: Department of Transportation or Proper Authority

The undersigned does hereby authorize the release and delivery of all motor vehicle driving records relating to the undersigned, including but not limited to personal information, to my employer/potential employer.

Name and Address of Employer:
Tipton Trucking, Inc.
397 Waterway Road
Oxford, PA 19063

This authorization shall continue in effect until revoked by the undersigned in a subsequent writing delivered to you.

Signature:
Date:
Full Name:
Address
Driver's License Number:
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: