Download Employment Application-Driver

Brokerage • Logistics • Transportation
8606 Victoria Ave., Riverside, CA 92504
[email protected]
Office:951-684-3444 | Fax:951-684-3443
Platinum-Enterprises.com
Position you are applying
for:
Check all that you may be interested in:
Full-Time
Part-time
Temporary:
Last Name
First Name
Middle Initial
Mailing Address
City
County
State
Zip
Driver’s License #
Cell Telephone
No.
Home Telephone No.
State
Expiration Date
Bus Phone
Operators
(Private Vehicle)
CDL
Are you claiming Veteran’s Preference? (Attach a copy of DD214 and/or service connected disability)
Have you ever been convicted of a felony? If you answered yes, please complete the following: (Conviction is
not an automatic bar to employment. Each case is considered on its individual merits).
Nature of Offense
Name & Location of Court
Date of Conviction
E-Mail Address
License Class
Endorsement
Yes
No
(Inaccurate information here will result in
disqualification.)
Yes
No
Are any of your records found under a different last name? If yes, please give the last name.
Previous Last Name
Yes
No
Are you currently employed by any affiliates of Platinum Enterprises? If yes, please give name:
Yes
No
Are you a former employee of Platinum Enterprises? If yes please give:
Last Date(s) of Employment
Department / Division
Yes
No
Have you ever been discharged or forced to resign from any position? If yes, please give employer, date and
reason. Employer
Date and Reason
Yes
No
Do you have any relatives working for Platinum Enterprises? If yes, please complete the following:
(Continue listing relatives on a separate page if necessary)
Name
Relationship
Department
Yes
No
If hired, are you authorized to work in the United States? For non-citizens, a copy of your authorization to
work issued by the U.S. Immigration and Naturalization Service must be submitted prior to appointment.
Do you now hold or are you a candidate for an elective public office?
Yes
No
Yes
No
For Office Use Only:
Date and Time Received
References
Name
Telephone Number
EDUCATION, TRAINING AND CERTIFICATIONS
Highest Grade Completed (choose one)
1
2
3
4
5
6
7
8
9
10
11
12
Elementary and High School Education
Name and Location of Last School Attended
Do you have a:
High School diploma
or
GED
YES
NO
YES
NO
(High School, Junior High or Elementary)
Accepted by: [
]
Name:
Location:
Driver Qualifications
Driver Licenses held
in the past 3-years
State
Expiration
Date
Class
Issue
Date
Restrictions
License #
License #
License #
The federal Motor Carrier Safety Regulations (49CRF391 Subpart E) requires that all driver applicants pass certain physical tests before they are hired to drive
a motor vehicle. Have you ever been granted a waiver under Section 391.49 of the Federal Motor Carrier Safety Regulations? Y/N
Date of last Department of Transportation Prescribed Examination?
Can you provide a copy? Y/N
List special courses or training that you will help you as a driver
List safe driving awards help and who awards were presented to:
List states operated in during the last five years
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Within the last 2-years have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you
applied for? Y/N
Within the last 2-years have you ever tested positive, or refused to test, on any type of drug or alcohol test administered by an employer?
Y/N
If you answered yes to either of the above, can you provide and/or obtain proof that you have successfully completed the DOT return to duty requirements?
Y/N
If you have answered yes to any of the above, Please Explain
Driver Experience
The federal Motor Carrier Safety Regulations (49CRF391.21 (b) (2) requires that driver applicants state their date of birth and SS#.
Date of Birth
Social Security #
Class of Equipment / Straight Truck, Tractor and Semi-Trailer, Twin, Other:
Type of Equipment / Van, Tank, Flat, Etc.:
Dates:
Approximate Miles:
Dates:
Approximate Miles:
Accident Review for the Past 3-Years (Attach a separate piece of paper if more space is needed).
Date
Nature of Accident
# of Fatalities
# of Injuries
# Vehicles Towed
Citations Issued
Date
Nature of Accident
# of Fatalities
# of Injuries
# Vehicles Towed
Citations Issued
Date
Nature of Accident
# of Fatalities
# of Injuries
# Vehicles Towed
Citations Issued
Date
Nature of Accident
# of Fatalities
# of Injuries
# Vehicles Towed
Citations Issued
Motor Vehicle Driving Record (MVR) Traffic Convictions and Forfeitures for the past 3-years other than parking tickets
Date
Location
# of Fatalities
Charge
Penalty
Date
Location
# of Fatalities
Charge
Penalty
Date
Location
# of Fatalities
Charge
Penalty
Date
Location
# of Fatalities
Charge
Penalty
Employment Record
The Federal Motor Carrier Safety Regulations (49CFR391.21) require that all applicants wishing to drive a commercial vehicle, list all employment for the last
3-years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for additional 7-years for a total of 10-years.
Any gaps in employment must be explained. Start w/ your most current position. You are required to list the complete mailing address, street # and zip code..
1
Starting Date
month / day / year
Ending Date
month / day / year
Hours per Week
Paid Work
Employer/Company Name and address (city and state are required)
Name & Title of Immediate Supervisor
Telephone Number
Volunteer
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job duties & include details of computer software used, equipment & tools used, guidelines followed, decisions made, reports completed, types of
communications, customer service details such as age groups served & other details that will provide for a clear understanding of your job.
2
Starting Date
month / day / year
Ending Date
month / day / year
Hours per Week
Paid Work
Employer/Company Name and address (city and state are required)
Name & Title of Immediate Supervisor
Telephone Number
Volunteer
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job duties & include details of computer software used, equipment & tools used, guidelines followed, decisions made, reports completed, types of
communications, customer service details such as age groups served & other details that will provide for a clear understanding of your job.
3
Starting Date
month / day / year
Ending Date
month / day / year
Hours per Week
Paid Work
Employer/Company Name and address (city and state are required)
Name & Title of Immediate Supervisor
Telephone Number
Volunteer
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job duties & include details of computer software used, equipment & tools used, guidelines followed, decisions made, reports completed, types of
communications, customer service details such as age groups served & other details that will provide for a clear understanding of your job.
4
Starting Date
month / day / year
Ending Date
month / day / year
Hours per Week
Paid Work
Employer/Company Name and address (city and state are required)
Name & Title of Immediate Supervisor
Telephone Number
Volunteer
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job duties & include details of computer software used, equipment & tools used, guidelines followed, decisions made, reports completed, types of
communications, customer service details such as age groups served & other details that will provide for a clear understanding of your job.
5
Starting Date
month / day / year
Ending Date
month / day / year
Hours per Week
Paid Work
Employer/Company Name and address (city and state are required)
Name & Title of Immediate Supervisor
Telephone Number
Volunteer
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job duties & include details of computer software used, equipment & tools used, guidelines followed, decisions made, reports completed, types of
communications, customer service details such as age groups served & other details that will provide for a clear understanding of your job.
6
Starting Date
month / day / year
Ending Date
month / day / year
Hours per Week
Paid Work
Employer/Company Name and address (city and state are required)
Name & Title of Immediate Supervisor
Telephone Number
Volunteer
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job duties & include details of computer software used, equipment & tools used, guidelines followed, decisions made, reports completed, types of
communications, customer service details such as age groups served & other details that will provide for a clear understanding of your job.
7
Starting Date
month / day / year
Ending Date
month / day / year
Hours per Week
Paid Work
Employer/Company Name and address (city and state are required)
Name & Title of Immediate Supervisor
Telephone Number
Volunteer
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job duties & include details of computer software used, equipment & tools used, guidelines followed, decisions made, reports completed, types
of communications, customer service details such as age groups served & other details that will provide for a clear understanding of your job.
CONDITIONS OF EMPLOYMENT STATEMENT
Under penalties of perjury, I declare that my answers to the questions on this application and any necessary examinations and supplements are true and
give Platinum Enterprises the right to investigate all information given and to secure additional appropriate information if necessary. I understand that
an investigative report may be made from information obtained through personal interviews with others. I understand that this inquiry may include
information as to my personal characteristics, employment verification, credential verification, personal identity verifications, reference checks,
criminal records, motor vehicle records, and appropriateness for employment. In accordance with the law and my understanding of this statement, I
authorize my current and former employers to give any information regarding my employment, together with all information regarding me, and hereby
release from all liability or responsibility all persons, companies, or corporations furnishing such information in good faith. I also authorize the release
of my scholastic ratings to Platinum Enterprises by schools and other education institutions that I have attended.
I understand that the completion of this application does not assure me of a position with Platinum Enterprises and does not obligate Platinum
Enterprises to use me in any way. I further understand that any misrepresentation herein WILL cause my application to be rejected, and/or
subject me to dismissal. Platinum Enterprises is committed to a drug free work place to protect the safety of workers and the public and will comply
with the Federal Drug Free Work Place Act.
I understand that this application, exam documents and attachments become a part of Platinum Enterprises records and will not be returned, reused or
copied for me once submitted. (It is recommended that you make a copy of this application for yourself before submitting it to the Human Resources
Department.)
Please read the minimum requirements (and application notes if the job is posted) before applying.
By my signature, I certify, authorize and acknowledge the above statements.
Signature
(Unsigned applications will not be considered)
Date
Social Security Number