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.
(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)
List your addresses of residency for the past 3 years.
Required for Commercial Drivers
(Answer only if a job requirement)
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.)
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:
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.
Previous addresses if less than 5 years: (Use back of page if more space is needed)
EDUCATION, TRAINING & CERTIFICATIONS
Name & Location(city/state)
Accident record for past 3 years
Traffic covictions for the past 3 years
List two Professional references by name and phone number:
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.