| APPLICATION FORM
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(ANSWER ALL QUESTIONS)
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In compliance with the Federal, State and Provincial equal employment opportunity laws, qualified applications are considered for all positions with out regard to race, color, religion, sex, national origin, age, marital status, or the presence of non job related medical condition or handicap.
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| Position(s) Applied for |
Date |
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| PERSONAL HISTORY |
| Name (first) |
(middle) |
(last) |
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| Address |
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| City |
Province/State |
Postal/Zip Code |
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| Phone |
Cell |
Email |
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| (If address above less than 3 years, list previous address below) |
| How long? |
Address |
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| City |
Province/State |
Postal/Zip Code |
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| How long? |
Address |
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| City |
Province/State |
Postal/Zip Code |
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| Can you supply proof of age? |
Are you FAST approved? |
S.I.N. |
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| In case of emergency notify |
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| Have you worked for this company before? |
| If Yes Date (from-to) |
Where? |
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| Rate of Pay |
Position |
Reason for leaving |
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| Are you employed now? |
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| If not, How long since leaving last employ? |
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| Who referred you? |
Rate of pay expected |
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| PHYSICAL HISTORY |
| List any handicap that prevents you from doing certain types of work |
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| Are you physically capable of heavy work? |
| Ever injured on the job? |
| Give nature and degree of injuries |
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| How much time lost from work in the past 3 years from illness? |
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| Would you be willing to take a physical examination? |
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| EMPLOYMENT HISTORY |
All driver applicants to drive in interstate commerce must provide the following information on all employees during the preceding 3 years.
Applicants to drive commercial motor vehicles' 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.)
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| Employer Name |
Date (from-to) |
Position |
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| Address |
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City |
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| Province/State |
Postal/Zip Code |
Phone |
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| Employer Name |
Date (from-to) |
Position |
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| Address |
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City |
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| Province/State |
Postal/Zip Code |
Phone |
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| Employer Name |
Date (from-to) |
Position |
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- |
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| Address |
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City |
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| Province/State |
Postal/Zip Code |
Phone |
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| *Includes vehicles having a GVWR of 26,001 lbs or more vehicle designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity required placarding. |
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| ACCIDENT RECORD FOR PAST 3 YEARS OR MORE |
| Last Accident (Description) |
Date |
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| Nature of Accident |
Fatalities |
Injuries |
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| Next Previous Accident (Description) |
Date |
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| Nature of Accident |
Fatalities |
Injuries |
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| Next Previous Accident (Description) |
Date |
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| Nature of Accident |
Fatalities |
Injuries |
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| Traffic convictions and forfeitures for the past 3 years (other than parking tickets) |
| Location |
Date |
Charge/Penalty |
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| Location |
Date |
Charge/Penalty |
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| Location |
Date |
Charge/Penalty |
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| EDUCATION |
| Highest Grade Completed |
School Attended |
City |
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| EXPERIENCE AND QUALIFICATIONS (DRIVER) |
| Province/State |
Licence Number |
Type and Expiration |
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| Province/State |
Licence Number |
Type and Expiration |
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| Have you ever been denied a licence, permit or privilege to operate a motor vehicle? |
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| Has any licence permit or privilege ever been suspended or revoked? |
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| If the answer to either is yes, please give details |
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| DRIVING EXPERIENCE |
| Class of Equipment: STRAIGHT TRUCK |
| Type of Equipment |
Dates (from-to) |
Approx. Total Distance |
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| Class of Equipment: TRACTOR AND SEMI TRAILER |
| Type of Equipment |
Dates (from-to) |
Approx. Total Distance |
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| Class of Equipment: TRACTOR-TWO TRAILERS |
| Type of Equipment |
Dates (from-to) |
Approx. Total Distance |
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| Class of Equipment: |
| Type of Equipment |
Dates (from-to) |
Approx. Total Distance |
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| List states operated in for the last 5 years |
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| List special courses or training that will help you as a driver |
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| Which safe driving awards do you hold and from whom? |
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| Describe any trucking, transportation or other experience that may help in your work for this company |
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| List courses and training other than shown elsewhere in this application. |
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| List special equipment or technical material you can work with (other than already shown). |
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| ADDITIONAL INFORMATION (notes from above) |
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TO BE READ AND AUTHENTICATED BELOW
This certifies that I completed this application, and that all entries on it and information in it are true and completed to the best of my knowledge.
I authorize you to make such investigations and inquiries of my personal, employment, fincancial or medical history and other related matters as may be necessary in arriving at a decision, I hereby release employers, schools or persons from all liability in responding to inquiries in connection with my application.
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, as permitted by law.
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Applicant |
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