Collins Concrete

DRIVERS APPLICATION FOR EMPLOYMENT

APPLICANT NAME (*)

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DATE OF APPLICATION

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COMPANY TREFFINGER INC DBA COLLINS CONCRETE

ADDRESS 12650 RAVENVIEW RD

CITY DALLASSTATE TX ZIP 75253

In compliance with Federal and State equal employment 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 group status.

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 l am required to abide by all rules and regulations of the Company.

I understand that information l 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 49 CFR 391.23(d} and (e). I understand that I have the right to:

Review information provided by previous employers;
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 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.

Signature(*)

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Date

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COMMERCIAL DRIVER APPLICATION

COMPANY TREFFINGER INC DBA COLLINS CONCRETE

ADDRESS 12650 RAVENVIEW RD _______________

CITY_DALLAS STATE_TEXAS ZIP 75253

APPLICANT INFORMATION

Date of application commercial

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Position applying for:

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Name:

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Phone:

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Emergency Phone:

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Age:

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Date of Birth:

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SSN#

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(The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are 40 years of age or older.)

PHYSICAL EXAM EXPIRATION DATE

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CURRENT & PREVIOUS THREE YEARS ADDRESSES:

Address 1

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Address 2

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Address 3

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HAVE YOU WORKED FOR THIS COMPANY BEFORE?

YesNo Invalid Input

If yes, give dates:

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Reason for leaving?

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EDUCATION HISTORY:

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DRIVING EXPERIENCE

Class of Equipment From – To Approximate number of miles

Straight Truck

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Tractor – Semi-Trailer

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Tractor – Two-Trailer

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Tractor – Triple Trailers

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Other

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List states operated in for the last five (5) years

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List special courses/training completed

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List any Safe Driving Awards you hold and from whom

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Accident Record for past three (3) years-attach sheet if more space is needed:

Date of Acc Nature of Acc Location/ Acc Fatalities People Injured

Accident report

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Accident Record

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Traffic Convictions and Forfeitures for the last three (3) years [other than parking violations]:

Traffic Convictions and Forfeitures for the last three (3) years [other than parking violations]:

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Driver’s License (list each driver’s license held in the past three (3) years:

Drivers Licenses

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

YesNo Invalid Input

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

YesNo Invalid Input

Is there a reason you might be unable to perform the functions of the job for which you have applied: as described in the job description?

YesNo Invalid Input

Have you ever been convicted of a felony?

YesNo Invalid Input

If the answers to any questions listed above are “yes” give details

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JOB REFERENCES

List three (3) persons for references, other than family members, who have knowledge of your safety habits

Name

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Address

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Phone:

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Name

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Address

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Phone:

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Name

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Address

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Phone:

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To Be Read and Signed by Applicant:
It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier of his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether some is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-308, I have been told that this investigation may include investigating Consumer Report, including information regarding any character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete any application file.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

This certifies that this application was completed by me and that all entries on it and information in it are true and complete to be best of my knowledge.

Applicant Signature(*)

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Applicant Signature

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FORMER EMPLOYER VERIFICATION

SECTION 1: PREVIOUS EMPLOYEE INFORMATION & RELEASE

Name:

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SSN:

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I hereby authorize {Ver Name:body} to release the following requested information to Treffinger Inc. dba Collins Concrete for the purpose of investigation for qualifying me to drive a commercial motor vehicle as required by the U.S. Department of Transportation & Federal Motor Carrier Safety Regulations Parts 382, 391, 392 & 49 CFR Part 40. You are herby released from any and all liability that may result from furnishing such information. Your quick response to the request will be greatly appreciated.

Signature

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Date:

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SECTION 2: PREVIOUS EMPLOYEE WORK HISTORY

Employed from

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Did previous employee drive a motor vehicle for you?

YesNo Invalid Input

If yes, please indicate the specific type of vehicle and time driven:

Straight Truck

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Tractor/Semi-Trailer

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Other

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If a trailer please specify type of trailer

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Was previous employee a safe and efficient driver?

YesNo Invalid Input

Did employee have any accidents/incidents, please advise:

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Was previous employee’s general conduct satisfactory?

YesNo Invalid Input

Reason for leaving?

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Is employee eligible for rehire, please advise

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SECTION 3: NOTE REGULATIONS OF THE DEPT OF TRANSPORTATION [49 CFR PART 40] requires your company to provide us with information concerning named driver’s past drug and alcohol test results, including refusals to be tested.

In the past two years, has the previously named applicant ever:
Tested positive for a controlled substance
Tested with an alcohol concentration of 0.04 or higher
Refused to submit to a DOT drug or alcohol test, including a verified adulterated or substituted result
Had any other violations of DOT drug/alcohol testing requirements?
Had any other violations of drug/alcohol regulations from previous employers?

Name:

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Title

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Signature

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date

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Telephone

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TREFFINGER INC DBA COLLINS CONCRETE (“The Company”) may request an investigative consumer report about you from a third-party consumer reporting agency such as iiX or IntelliCorp Records, Inc. for employment (including independent contractor or volunteer assignments, as applicable). An “investigative consumer report” is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews). The most common form of an investigative consumer report in connection with your employment is a reference check through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, or mode of living. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.

You have the right, upon written request made within a reasonable time, to request:
(1) whether an investigative consumer report has been obtained about you,
(2) disclosure of the nature and scope of any investigative consumer report and
(3) a copy of your report.

iiX, a unit of ISO Claim Services, Inc., can be contacted by mail at 1716 Briarcrest Drive, Suite 200; Bryan, TX 77802; or phone: 800-299-7099; or website: www.iix.com.

IntelliCorp Records, Inc. can be contacted by mail at 3000 Auburn Dr, Suite 410; Beachwood, OH 44122; or phone: 1-888-946-8355; or website: www.intellicorp.net. IntelliCorp Record, Inc., 3000 Auburn Drive, Suite 410, Beachwood, Ohio 44122; Tel. No. 1.888.946.8355; www.intellicorp.net .

The scope of this disclosure is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of investigative consumer reports to the extent permitted by law.

Signature(*)

Sign Above

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Date:

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TREFFINGER INC DBA COLLINS CONCRETE (“the Company”) may obtain information about you from a third-party consumer reporting agency for employment Thus, you may be the subject of a “consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your criminal history, social security verification, motor vehicle records (“driving records”).

You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you and to request a copy of your report. These searches will be conducted by IntelliCorp, 3000 Auburn Drive, Suite 410, Beachwood, Ohio 44122; Tel. No. 1.888.946.8355; www.intellicorp.net or by iiX, a unit of ISO Claim Services, Inc., 1716 Briarcrest Drive, Suite 200, Bryan, TX 77802, Tel No 1.800.299.7099: www.iix.com

signature(*)

Sign Above

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Date

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I am authorizing the release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer to TREFFINGER INC DBA COLLINS CONCRETE This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released is limited to the following DOT-regulated testing items:

Alcohol tests with a result of 0.04 or higher;
Verified positive drug tests;
Refusals to be tested;
Other violations of DOT agency drug and alcohol testing regulations;
Information obtained from previous employers of a drug and alcohol rule violation;
Documentation, if any, of completion of the return-to-duty process following a rule violation.

I also consent to have any legally required notices sent electronically

Printed Name

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Signature(*)

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Parent or Legal Guardian Signature

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Date

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Date

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Last Name

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First Name

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Middle Name

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Current Address

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Dates Lived Here

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Date of Birth

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Other Names Used

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Years Used

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Driver's License #

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DL State

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Email address

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DRIVERS APPLICATION FOR EMPLOYMENT

Collins Concrete

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