KILLER B TRUCKING, INC.

Transcription

1 KILLER B TRUCKING, INC. HOME OFFICE RTH DAKOTA OFFICE 2078 Westgate Drive rd Street NW Rock Springs, Wyoming Watford City, ND Application for Employment Instructions to applicant- Fill application out completely, accurately and read carefully. 10 years of work/employment history should be provided leaving no gaps (If applicant was un-employed or attending school, please state so on the application). Resume may be attached but does not permit applicant to omit work history section. Current MVR should be provided from applicants who wish to apply for a job where a company vehicle may be driven (Sand hauler/truck Driver, Field Coordinator ) Information provided will be verified and could affect your eligibility for employment. Incomplete applications will not be considered. APPLICANT INFORMATION Last Name First M.I. Date Please print any other names you have used Current Street Apartment/Unit # Mailing City State ZIP LIST THREE YEARS OF PREVIOUS ADDRESSES IF AT CURRENT ADDRESS LESS THAN THREE YEARS Previous Previous Phone Emergency Contact Name Date Available Emergency Number Social Security No. City City How long have you lived at this address? State ZIP State ZIP Contact Desired Salary Position Applying for Desired Work Location WYOMING RTH DAKOTA How did you hear about this company? Are you age 18 or over? YES Physical Exam Expiration Date Are you legally eligible for employment in the United States? Have you ever worked for this company before? YES Have you ever been convicted of a felony? YES Are you a registered sex offender? YES YES If so, when? If yes, explain Can you perform the duties for the job you are applying for? YES Are there any specific times or days that you cannot work? YES If so when? EDUCATION High School From To Did you graduate? YES Degree College From To Did you graduate? YES Degree Other From To Did you graduate? YES Degree

2 PREVIOUS AND CURRENT EMPLOYMENT START WITH THE MOST RECENT May we contact your previous supervisor for a reference? YES Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES testing requirements as required by 49 CFR Part 40? YES May we contact your previous supervisor for a reference? YES Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES testing requirements as required by 49 CFR Part 40? YES May we contact your previous supervisor for a reference? YES Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES testing requirements as required by 49 CFR Part 40? YES May we contact your previous supervisor for a reference? YES Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES testing requirements as required by 49 CFR Part 40? YES

3 MILITARY SERVICE Branch From To Rank at Discharge SPECIAL SKILLS Please list any special skills, courses or certificates you have or any equipment you have been trained to operate and date of completion. For example: office equipment, forklifts, welding certificate, DOT training, computers, etc. SPECIAL TRAINING Have you had any of the trainings listed below? IF YES WRITE IN COMPLETION DATE-PROOF OF COMPLETION WILL BE REQUIRED OSHA 10 GENERAL INDUSTRY YES Contractor Orientation YES SAFELAND YES FIRST AID / CPR YES DEFENSIVE DRIVING YES LIST ANY SAFETY OR SPECIAL AWARDS-INCLUDE DATE- All Applicants must provide Driver s License information. Applicants applying for a position where you will drive ANY company vehicle must complete this section entirely Applicants MUST return a current MVR with your completed employment application and must comply with the insurance guidelines provided by the insurers of Killer B Trucking, Inc. in order to be considered for employment List any Traffic convictions and forfeitures for the last three years(other than parking violations) If None write None Violation Date Location of Violation - list City, State and County Charge (Be specific for example: Include Zone speed and mph over if speeding) Penalty List any Accidents you were involved in during the past three years regardless of fault(use the back if necessary) If None write None Accident Date Accident Location - list City, State and County Nature / Description of Accident Fatalities People Injured List any Driver s Licenses you have held in the past three years State Driver s License Number Type (Class) Endorsements Restrictions Expiration Date Class of Equipment Straight Truck Tractor and Semi Trailer Tractor two trailers (doubles) Other Type of Equipment (Van, Pneumatic, Flatbed ) From Date To Date Approximate Number Of Miles (Total) Have you ever been denied a license, permit or privilege to operate a motor vehicle? Has any license, permit or privilege ever been suspended or revoked? YES If YES Explain YES If YES Explain

4 REFERENCES Please list three professional references Full Name Phone ( ) Full Name Phone ( ) Full Name Phone ( ) DISCLAIMER AND SIGNATURE I certify that I have read and understand all of the information on this application and that this application was completed by me. I also certify that all of my answers are true and complete to the best of my knowledge. Questions regarding this application or this statement should be directed to any employment interviewer before signing. The application will be given every consideration, however its receipt does not imply that the applicant will be interviewed or employed. I also understand that that the employer may investigate my background to ascertain any and all information of concern to my possible employment. In connection with my application for employment, I understand and agree that background inquires may be requested by Killer B Trucking, Inc. or on behalf of Killer B Trucking, Inc. that will seek information as to my character, work habits, including oral assessments of my job performance, experiences and abilities, along with reasons for termination of past employment. I also understand and agree that Killer B Trucking, Inc. may request information from various federal, state, and other agencies, including public and private sources which maintain records concerning my past activities relating to my driving record, credit history, criminal record, civil matters, previous employment, educational background and other past experiences. I hereby release Killer B Trucking, Inc. and it s agents from any/all liability of whatever kind and nature which, at any time, could result from obtaining such information. I also understand that if hired my consent will apply throughout the term of my employment. I understand that should an offer of employment be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of Killer B Trucking, Inc. However, I further understand that none of the policies, rules, nor regulations of employment, or any representation, whether oral or written by any representative or agent of the company, at any time, can constitute a contract of employment. I understand that any employment offered is for an indefinite duration and at will and that either I or Killer B Trucking, Inc. may terminate my employment at any time with or without notice or cause. I also understand that Killer B Trucking, Inc. is a drug free workplace and I will be asked to complete and pass a drug test and/or alcohol test in accordance with company policy and/or FMCSR Section Motor Carrier company must receive verified negative test results for the applicant to be eligible for employment. I also understand that if this application leads to employment that I will be subject to laws and/or policies requiring additional and continuing Drug and Alcohol testing under numerous situations including but not limited to Preemployment, Random and Reasonable Suspicion testing as stated in FMCSR Part 382 and/or Killer B Trucking, Inc. company policy. Verified positive test results will result in ineligibility for employment and referral If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Applicants Date DRIVER APPLICANT DRUG AND ALCOHOL PRE-EMPLOYMENT STATEMENT CFR PART (j) requires the employer to ask any applicant whether he or she has tested positive or refused to test on any pre-employment drug and/or alcohol test administer by an employer to which the employee applied for, but did not obtain safety sensitive transportation work covered by DOT agency drug and alcohol rules during the past two (2) years. If the potential employee admits that he/she had a positive test, potential employee must provide Killer B Trucking, Inc. documentation for successful completion of SAP requirements in order to be eligible for consideration of employment. As an applicant applying to perform safety sensitive functions for our company, you are required to respond to the following questions: Have you tested positive or refused to test on any pre-employment drug and/or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? YES IF YOU ANSWERED YES TO THE ABOVE QUESTION, Can you provide proof that you have successfully completed the DOT return to duty requirements? YES MY SIGNATURE BELOW CERTIFIES THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT Applicant Date

5 IMPORTANT TICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service 1. In connection with your application for employment with KILLER B TRUCKING, INC ( Prospective Employer ), it may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: 2. I authorize KILLER B TRUCKING, INC ( Prospective Employer ) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. 3. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. 4. Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above. Date: Name (Please Print) Fair Credit Reporting Act Disclosure Statement In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law , as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law ), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections , , and of the Federal Motor Carrier Safety Regulations. Name (Please Print) Date Social Security Number

6 Request for Previous Employee work history and employment verification Requested by: Killer B Trucking, Inc. Phone (307) Westgate Drive Fax (307) Rock Springs, WY POTENTIAL EMPLOYEE / APPLICANT STATEMENT OF RELEASE AS AN APPLICANT OR POTENTIAL EMPLOYEE FOR POSITION OF AT KILLER B TRUCKING, INC. I UNDERSTAND THAT AS PART OF THEIR BACKGROUND CHECKING PROCEDURE AND OR FEDERAL MOTOR CARRIER SAFETY REGULATIONS PART THE FOLLOWING INFORMATION WILL BE REQUESTED FROM ALL PREVIOUS EMPLOYERS LISTED ON MY APPLICATION WITHIN THE LAST THREE YEARS OF MY EMPLOYMENT. I ALSO ACKWLEDGE THAT THIS INFORMATION WILL BE USED IN DETERMINING MY ELIGIBILITY TO BE HIRED, THAT I HAVE THE RIGHT TO REVIEW THIS INFORMATION AND REBUT ANY ERRORS IN THESE STATEMENTS FROM MY PRIOR EMPLOYERS. I HEREBY AUTHORIZE THIS COMPANY TO RELEASE ALL RECORDS OF EMPLOYMENT INCLUDING ASSESSMENTS OF MY JOB PERFORMANCE, ABILITY AND FITNESS, DRIVING PERFORMANCE, INCLUDING DATES OF ANY AND ALL VEHICLE INCIDENTS OR ACCIDENTS; AND ALL ALCOHOL OR DRUG TESTS INCLUDING VERIFIED TESTS AND REFUSALS TO BE TESTED. ANY REHABILITATION COMPLETION UNDER DIRECTION OF SAP/MRO OR ANY N DOT PROGRAMS IN WHICH MY PREVIOUS EMPLOYER PARTICIPATES. I HEREBY RELEASE THIS COMPANY AND ITS EMPLOYEES, OFFICERS, DIRECTORS AND AGENTS FROM ANY AND ALL LIABILITY OF ANY TYPE AS A RESULT OF PROVIDING INFORMATION TO KILLER B TRUCKING, INC. APPLICANT PRINTED NAME TODAY S DATE DOB APPLICANT SIGNATURE SOCIAL SECURITY NUMBER PREVIOUS EMPLOYER TO COMPLETE: PLEASE PROVIDE THE FOLLOWING INFORMATION AS PERMITTED PER YOUR COMPANY POLICIES AND/OR AS REQUIRED BY FMCSR 391 FOR PREVIOUS EMPLOYEES WHO WERE: DOT (FMCSR) REGULATED EMPLOYEES PLEASE COMPLETE ALL SECTIONS N DOT EMPLOYEES PLEASE COMPLETE SECTIONS N DOT EMPLOYEES WHO PARTICIPATED IN COMPANY D & A PROGRAM COMPLETE SECTIONS N DOT EMPLOYEES WHO DROVE COMPANY MOTOR VEHICLE COMPLETE SECTION SECTION 1 General Employment Information He/She was employed for you as from / / to / / Reason for leaving Would you re-employ this person? YES Upon Review Please Explain Wage information upon separation: Hourly wage or Salary SECTION 2 Drug and Alcohol Information Any Alcohol Test with a result of.04 or higher alcohol concentration? YES Any Verified positive drug test? YES Any refusals to be tested (including verified adulterated or substituted drug test results? YES Any other violations of DOT agency drug and alcohol testing regulations (Part 382 or 40)? YES If he/she successfully completed rehabilitation referral and remained under your employ, did he/she have any subsequent violations for: N/A Alcohol test result of.04 or greater? YES A verified positive drug test or refusal to test (including verified adulterated/substituted drug result? YES Please provide copy of documentation of successful completion of an SAP evaluation, prescribed treatment and return to duty requirements (including follow up tests) if they remained in your employ or if you received such documentation from another previous employer

7 SECTION 3 Driving / Operating and Accident Information Did the previous employee drive a company vehicle or operate equipment for you? YES What type of equipment did they operate? Tractor/Trailer Doubles Triples Other Type of Trailer pulled Straight Truck Pick up or light vehicle not requiring Commercial Driver s License Forklift Loader Other Was the employee a safe driver/operator? YES If please explain Convicted of any traffic violations? YES If YES please list date and type License suspended, revoked or denied? YES If YES please explain Motor Carriers/DOT regulated employers please provide accident information as required by FMCSR on any accidents as defined by and/or from your accident register (FMCSR ) which the above named previous employee was involved in within the past three years while under your employment. Please provide any other important minor accident/incident information at your discretion or in compliance with your company policy. All other employers please provide any information accident/ incident information at your discretion or in compliance with your company policy you feel could be pertinent or applicable safety information. If there is no accident information for this employee please check here DATE LOCATION (Please give City/Town or closest, and state Vehicles Towed Hazmat Spill? Fatalities Injuries PREVIOUS EMPLOYER REPRESENTATIVE SUPPLYING INFORMATION Print Name Title Date