APPLICATION FOR EMPLOYMENT

APPLICANT NAME

DATE OF APPLICATION

COMPANY TREFFINGER INC DBA COLLINS CONCRETE

ADDRESS 12650 RAVENVIEW RD

CITY DALLAS STATE 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.

initial

Check to agree all information is correct

COMPANY TREFFINGER INC DBA COLLINS CONCRETE

ADDRESS 12650 RAVENVIEW RD

CITY DALLAS STATE TX ZIP 75253

Date of application commercial

Position applying for:

Full Name

Phone Number

Emergency Number

Age

Date of Birth

SSN#

(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

CURRENT & PREVIOUS THREE YEARS ADDRESSES:

Address 1

Address 2

Address 3

HAVE YOU WORKED FOR THIS COMPANY BEFORE?

If yes, give dates:

Reason for leaving?

–HIGHEST EDUCATION HISTORY:–

EMPLOYMENT HISTORY

CURRENT & PREVIOUS THREE YEARS ADDRESSES:

Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self-employment periods, and all commercial driving experience for the past ten (10) years.

FROM DATE

TO DATE

Employer Name

Position Held

Address

Reason for leaving?

Were you subject to the FMCSRs while employed here?

Yes No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

DOT-regulated mode subject to the drug and alcohol testing

Yes No

FROM DATE

TO DATE

Employer Name

Position Held

Address

Reason for leaving?

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

DOT-regulated mode subject to the drug and alcohol testing

Yes No

FROM DATE

TO DATE

Employer Name

Position Held

Address

Reason for leaving?

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

DOT-regulated mode subject to the drug and alcohol testing

Yes No

Signature

DRIVING EXPERIENCE
Class of Equipment From – To Approximate number of miles

Straight Truck

Straight Truck

Tractor – Semi-Trailer

Tractor – Semi-Trailer

Tractor – Two-Trailer

Tractor – Two-Trailer

Tractor – Triple Trailers

Tractor – Triple Trailers

Other Vehicles

Tractor – Triple Trailers

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

Tractor – TList states operated in for the last five (5) years title Trailers

List special courses/training completed

List special courses/training completed

List any Safe Driving Awards you hold and from whom

List any Safe Driving Awards you hold and from whom

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

Accident report upload

Accident Record

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]:

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

Drivers Licenses

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

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

Yes No

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

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

Yes No

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?

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

Yes No

Have you ever been convicted of a felony?

Have you ever been convicted of a felony?

Yes No

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

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

Job Reference

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

Ref Name1

Ref Address 1

Ref Phone 1

Ref Name 2

Ref Address 2

Ref Phone 2

Ref Name 3

Ref Address 3

Ref Phone 3

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.

Applicant Signature (*)

Applicant Signature Type (*)