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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