SS#
Can you provide your ss# upon request? * Select Yes No
Phone *
Email *
Where did you hear about the Position? *
Only U.S. citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, submit documentation verifying your legal right to work and your identity? * Select Yes No
Have you ever been convicted of any crime? * Select YES NO
If yes, give dates and explain. (A conviction will not necessarily disqualify you from employment): *
Are you over the age of 18? * Select YES NO
High School name & address *
Grade/Years Completed * Select 9 10 11 12
Diploma * Select YES NO
College/University name & address *
Grade/Years Completed * Select 1 2 3 4
Diploma/Degrees *
Describe course of study *
Describe specialized training, apprenticeship, skills, and extracurricular activities
Honors received
Have you had prior job educational experience which relates to the job for which you are applying? * Select YES NO
If Yes explain *
Have you taken any illegal drugs in the last 30 days? * Select YES NO
Have you applied here before? * Select YES NO
Are you a veteran of the U.S. Military Service? * Select YES NO
If yes what branch *
Are you applying for a driving or sales position? Select Yes No
Drivers License #
State
Class
Drivers License #
State
Class:
Have you had any tickets? Select YES NO
If yes, explain *
Has your license ever been suspended or revoked? Select YES NO
If yes, explain *
Do you have any DUI or DWI convictions? Select YES NO
If yes, explain *
Yes/No Select YES NO
Type of Vehicle Select Van Tanker Refrigerated Dump Truck Flatbed
Aprox. Miles
Yes/No Select YES NO
Type of Vehicle Select Van Tanker Refrigerated Dump Truck Flatbed
Aprox. Miles
Yes/No Select YES NO
Type of Vehicle Select Van Tanker Refrigerated Dump Truck Flatbed
Aprox. Miles
Yes/No Select YES NO
Type of Vehicle Select Van Tanker Refrigerated Dump Truck Flatbed
Aprox. Miles
Yes/No Select YES NO
Type of Vehicle Select Van Tanker Refrigerated Dump Truck Flatbed
Aprox. Miles
Yes/No Select YES NO
Aprox. Miles
Yes/No Select YES NO
Aprox. Miles
Will you work overtime if asked? Select YES NO
Are there any hours, shifts or days you will not work? Select YES NO
If yes, explain *
Do you have any friends, relatives who work here? Select YES NO
If yes, please give names and relationships *
Are you now employed? Select YES NO
May we contact them? Select YES NO
Are you on a layoff? Select YES NO
Are you subject to recall? Select YES NO
Employer 1
Address
Title
Phone #
Hourly Rate / Salary - Starting/Final
Supervisor
May we contact? Select YES NO
Reason for leaving
Were you subject to the FMCSR while employed? Select YES NO
(Did you operate a vehicle requiring a CDL)? Select YES NO
Was your job designated as a Safety-Sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirement of 49CFR Part 40? Select YES NO
Employer 2
Address
Title
Phone #
Hourly Rate / Salary - Starting/Final
Supervisor
May we contact? Select YES NO
Reason for leaving
Were you subject to the FMCSR while employed? Select YES NO
(Did you operate a vehicle requiring a CDL)? Select YES NO
Was your job designated as a Safety-Sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirement of 49CFR Part 40? Select YES NO
Employer 3
Address
Title
Phone #
Hourly Rate / Salary - Starting/Final
Supervisor
May we contact? Select YES NO
Reason for leaving
Were you subject to the FMCSR while employed? Select YES NO
(Did you operate a vehicle requiring a CDL)? Select YES NO
Was your job designated as a Safety-Sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirement of 49CFR Part 40? Select YES NO
Employer 4
Address
Title
Phone #
Hourly Rate / Salary - Starting/Final
Supervisor
May we contact? Select YES NO
Reason for leaving:
Were you subject to the FMCSR while employed? Select YES NO
(Did you operate a vehicle requiring a CDL)? Select YES NO
Was your job designated as a Safety-Sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirement of 49CFR Part 40? Select YES NO
Please explain any gaps in your employment history:
Have you ever been forced to resign? Select YES NO
If yes, explain *
Did you receive any discipline in the last 12 months of active employment? Select YES NO
If yes, explain *
Were you given a performance evaluation within the last 12 months of active employment? Select YES NO
If yes, what was the range of scores used and what was your score: *
Have you ever signed any non-compete agreement with any other employer that would restrict you from working with this company? Select YES NO
If yes, explain *
Job applying for Warehouse (Full-Time) Merchandiser Accounting Clerk/Cashier
Salary requested
Date you can start
1) Name, address and phone#
Occupation
2) Name, address and phone#
Occupation
3) Name, address and phone#
Occupation
List below any information/remarks you wish to have considered as a part of your application
In lieu of signature, please type initials here *
In lieu of signature, please type initials here *
In lieu of signature, please type initials here *
In lieu of signature, please type full name *
