Application For General Employment

Application Form

Name *

First Name

Last Name

Best Email Address to Contact You *

Best Phone Number to Contact You *

Position(s) Applied For:*

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected status.*

I understand

List your addresses of residency for the past 3 years *

Street Address

City

State

Zip Code

Do you have the legal right to work in the United States? *

Yes

Date of Birth (Required for Commercial Drivers) *

Can you provide proof of age? *

Yes

Have you ever worked for this company before? *

Yes

Are you currently employed? *

Yes

Who referred you? *

Rate of pay expected *

Is there any reason you might be unable to perform the functions of the job for which you have applied?*

Yes

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. Press (+) if Applicable)

List of Employers (Press (+) if Applicable *

Employer

Dates of Employment

Position Held

Reason for Leaving?

Contact Person

Contact Phone Number

Employer

Dates of Employment

Position Held

Reason for Leaving?

Contact Person

Contact Phone Number

Were you subject to the FMCSRs* ** at any of these employers? *

Yes

Were any of your jobs designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? *

Yes

vehicle operating history

Have You Been In An Accident in the Last 3 Years? *

Yes

Have You Had a Traffic Conviction and/or Forfeiture in the past 3 years? (Other than parking violations) *

Yes

Please list current driver's licenses or permits held: *

License No.

State

Class

Endorsement(s)

Expiration Date

Have you ever been denied a license, permit or privilege to operate a motor vehicle? *

Yes

Has any license, permit or privilege ever been suspended or revoked? *

Yes

criminal history

Please note that a "Yes" answer to any of the following questions will not necessarily disqualify you from employment.

Have you been convicted of any Felonies and/or Misdemeanor(s) in the last 10 years? *

Yes

Please fill in the information below about your driving experience.

List special equipment or technical materials you can work with (other than those already shown)

education history

List highest high school grade completed: *

List years in college completed: *

Name of last school attended *

City and State of last school attended *

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 to 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 interview(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 that I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49CFR 391.23(d) and (e). I understand that I have the right to: 1) Review information provided by previous employers; 2) 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 3) 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. *

Yes

I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge *

Yes

Electric Signature - Please type your First and Last Name.*

First Name

Last Name

Acceptance *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

I don't understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Default label *

I understand and accept conditions.

I don't understand and accept conditions.

9465 Counselors Row Suite 110A, Indianapolis IN 46240
317-804-1888
sales@dbetrucks.com

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