EMPLOYMENT OPPORTUNITY

colliertowing

(print)

In compliance with Federal and State equal  employment  opportunity  laws,  qualified  applicants are considered for all positions without regaro 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  t«  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  inter- view(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  contacted1 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.

PROCESS RECORD

(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE LACED IN FILE)

TERMINATION OF EMPLOYMENT

This form is made available with the  understanding  that J.J. Keller & Associates,  Inc. is not engaged in rendering legal, accounting, or other professional services.

J. J. Keller & Associates, Inc. assumes no responsibility for the use of this form, or any decision made by an employer which may violate local, state, or Federal law.

? Copyright 2005 J. J. KELLER & ASSOCIATES. INC.. Neenah, WI •  USA

 (800) 327-6868  • www.jjkeller.com  • Printed in the United States

APPLICANT TO COMPLETE

(answer all questions  – please print)

First

List your addresses of residency for the past 3 years.

Current Address

yr./mo.

Previous Addresses

yr./mo.
yr./mo.
yr./mo.
Required for Commercial Drivers

Dates

(Answer only if a job requirement)

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.  Add  another sheet as  necessary.)

EMPLOYER

DATE

yr./mo.
yr./mo.
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?

The fact that you have filled out this application will be kept strictly  confidential and will not in any way  be  brought  to  the attention  of  your present employer without your permission. Please give an accurate, detailed, and complete record of your employment Make sure that you list the full name of the person to whom you reported and the phone number for each employer. Begin with your present position.

We must have a complete list of your past employers for the last 3 years.(use back of page if needed)

Most Recent Employer:

Date of employment

#2 Employer:

Date of employment

#3 Employer:

Date of employment

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY: THEY CONSITUTE THE CONDITIONS WHICH YOU MAY BE EMPLOYED

The information that I have provided herein is accerate to the best of my knowledge. I hereby authorize collier Towwing and/or its agents to investigate my background and to verify any and all information of concern to my records,whether such information is favorable or unfavorable to me. I understand that any material misrepresentation or deliberate omission of a fact in my application may be justification for refusal of employement, or if employed termination from the company. In consideration of  my employment, I understand  that my employment is at will and can be terminated,with or without cause,and with or without notice,at any time at the option of either the Company or myself. I acknowledge that the copy of this dcoument carries the full force of the original document for legal purposes.I do hereby agree to forever release and discharge Valley Towing,their agents, and their associates to the full extent permitted by law from  any claims,damages,losses,liabilities,costs,and expenses,or any other charge or complaint filedmwith any agency arising from the retrieving and reporting information.

Employment Application

Previous addresses if less than 5 years: (Use back of page if more space is needed)
Have you ever been convicted of a criminal offense?

EDUCATION, TRAINING & CERTIFICATIONS

Level

Name & Location(city/state)

Year Graduated

Driving experience:

Accident record for past 3 years

Traffic covictions for the past 3 years

Have you ever been denied a license,permit or privilege to operate a motor vehicle:
Has any license,permit or privilege to operate a motor vehicle been suspended or revoked:
Are you legally permitted to work in this Country?
Is current DMV print out submitted(Required)
How were you referred to us?

List two Professional references by name and phone number:

Are you currently employed?
May we contact your present employer before hiring?
May we contact you at your present employer:
Do you intend to submit a resume as part of your application?

MOTOR VEHICLE DRIVER’S CERTIFICATION OF VIOLATIONS

I certify that the following is a true and complete list of traffic violations(other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months.

If no violations are listed above, I certify that I have  not been convicted or forfeited bond or collateral on account of any violation required required to be listed during the past 12 months

NOTICE TO DRIVER APPLICANTS CONTROLLED SUBSTANCES TESTING REQUIREMENT

Our compnay has a vital interest in maintaining safe,healthful and efficient working conditions for our customers,the public,and our drivers. Using or being under the influence of alcohol and/or controlled substances on the job may pose serious safety and health risks not only for the user,but to all those who work with the user. The possession,use or sale of alcohol or an illegal controlled substances poses unacceptable risks to safe, healthful and efficient operations

To meet this compelling interest ,and in compliance with the Department of transportation’s Alcohol and Controlled Substances Testing Requirement (49 CFR Part 382) drivers who wish to be consdered for employment must agree to SUBMIT TO PRE-EMPLOYMENT CONTROLLED SUBSTANCES TESTING. All pre-employment drug tests will be conducted only after a contingent offer of employment is made.

By completing and signing this Notice and the attached Apllication of Employment, the driver applicant understands to submit to pre-employment controlled substances testing as provided for in the DOT Alcohol and Controlled Substances Policy.

ANY DRIVER APPLICANT WHO IS UNWILLING TO AGREE TO THESE CONDITIONS SHOULD NOT APPLY FOR EMPLOYMENT. Refusal of driver applicant to agree to controlled subsctances testing at this time does not precude applying for employment at some future date.