Date* MM slash DD slash YYYY Name* First Last Phone*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Have you been at the above residence less than 3 years?* Yes No If yes, list all residences for the past 3 years:StreetCityStateZip Code (Use + button to add more)Do you have the legal right to work in the United States?* Yes No Date of Birth* MM slash DD slash YYYY Can you provide proof of age? What type?* Required for Commercial DriversIn case of emergency, notify:* First Last Emergency Contact Phone*Position(s) applying for:* Please review open positions on our Employment page.Type of hours:* Part-time Full-time Who referred you?* First Last Rate of pay expected:*Are you currently employed?* Yes No If not, how long since leaving last employment? EducationHigh grade completed:* 8 9 10 11 12 College: 1 2 3 4 Last school attended:* List special courses or training that will help you as an employee:General InformationHave you ever been convicted of a felony?* Yes No If yes, please explain fully:Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.Physical HistoryIs there any reason you might not be able to perform the functions of the job for which you have applied?*For drivers only: Date of last ICC physical examination: Employment HistoryThe U.S. Department of Transportation requires that driver applicants show all employment for the past three years. Effective July 1987, must also show commercial driver employment for the seven years immediately proceeding this three-year period. Section 391-21 (b) (10), (11). Start with the last or current position, including military experience, and work back.Current Employer Contact Person First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhonePosition Held Dates of employment: Wage Reason for leaving: Did you drive a vehicle requiring a CDL? Yes No Previous Employer Contact Person First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhonePosition Held Dates of employment: Wage Reason for leaving: Did you drive a vehicle requiring a CDL? Yes No Previous Employer Contact Person First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhonePosition Held Dates of employment: Wage Reason for leaving: Did you drive a vehicle requiring a CDL? Yes No Driver Experience & QualificationsHave you ever been denied a license or privilege to operate a motor vehicle?* Yes No If yes, please explain:Has any license, permit, or privilege ever been suspended or revoked?* Yes No If yes, please explain:Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?* Yes No If yes, please explain:Class of Equipment: Straight TruckDates DrivenApprox. Miles DrivenClass of Equipment: Tractor & Semi-TrailerDates DrivenApprox. Miles DrivenClass of Equipment: Twin TrailersDates DrivenApprox. Miles DrivenClass of EquipmentOtherDates DrivenApprox. Miles DrivenList states operated in during the last five years:*List special courses or training that will help you as a driver:List safe driving awards help and who awards were presented by:Do you have any accidents on record in the past 3 years?* Yes No If yes, please explain:Nature of AccidentFatalitiesInjuries List most recent first. (Use + button to add more)Have you had any traffic convictions or forfeiturers in the past 3 years?* Yes No Other than parking violations.If yes, please explain:LocationDateChargePenalty (Use + button to add more)Equipment Operator Experience & QualificationsEquipment Operation ExperienceType of equipment operatedDates operated fromApprox. Hours (Use + button to add more)List special courses that will help you as an operator:Maintenance Experience & QualificationsList courses and training in maintenance work:Drive Line ComponentsFormal TrainingExperienceDiesel Engine CheckFormal TrainingExperienceTrailer Service RepairFormal TrainingExperienceBrakes, including adjustmentFormal TrainingExperienceInspectionsFormal TrainingExperienceGeneral Truck RepairFormal TrainingExperienceSignatureIt is understood and agreed that Dulas Excavating Inc. may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employer and persons named herein from all liability for any damages on account of his/her furnishing such information. It is also understood and agreed that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an Investigative 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 employment file. I understand that this application is not an employment contract and that, if hired, my employment and compensation can be terminated, with or without cause, at any time at the option of either the company or myself. This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Date* MM slash DD slash YYYY Signature*NameThis field is for validation purposes and should be left unchanged. Δ
