Applicant Name

Last

First

Middle

Date

Position Applied for

Current Address

Street

City

State

Zip Code

Previous Addresses

Street

City

State

Zip Code

Date of Birth

Home Phone

Cellular Phone

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 Falzone Towing Services, Inc., to make such investigations and inquiries of my personnel, 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 I am required to abide by all rules and regulations of Falzone’s Towing Service, Inc.

I understand that information I 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 employer(s) to resend 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

Date

Have you ever been convicted of a crime other than moving violations, including DUI?

YesNo

If yes, state the offense, location, date and disposition:

Conviction of a crime is not an automatic bar to employment all circumstances will be considered.

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* 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.)

Employer #1

Name

Start Date

End Date

Address

Street

City

State

ZIP Code

Position

Salary/Wage

Contact Person

Phone Number

Reason for Leaving

Were you subject to the FMCSRs+ while employed?

YesNo

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?

YesNo

Employer #2

Name

Start Date

End Date

Address

Street

City

State

ZIP Code

Position

Salary/Wage

Contact Person

Phone Number

Reason for Leaving

Were you subject to the FMCSRs+ while employed?

YesNo

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?

YesNo

Employer #3

Name

Start Date

End Date

Address

Street

City

State

ZIP Code

Position

Salary/Wage

Contact Person

Phone Number

Reason for Leaving

Were you subject to the FMCSRs+ while employed?

YesNo

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?

YesNo

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

+The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designated or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Accident record for past 3 years or more. If none, write none

Accident #1

Date

Nature of Incident

Fatalities

Injuries

Hazardous Material Spill

Accident #2

Date

Nature of Incident

Fatalities

Injuries

Hazardous Material Spill

Accident #3

Date

Nature of Incident

Fatalities

Injuries

Hazardous Material Spill

Traffic convictions and forfeitures for the past 3 years (Other than parking violations). If none, write none

Traffic Conviction #1

Location

Date

Charge

Penalty

Traffic Conviction #2

Location

Date

Charge

Penalty

Traffic Conviction #3

Location

Date

Charge

Penalty

Experience and Qualifications-Driver

List all Driver Licenses or permits held in the past 3 years

Driver License

State

License Number

Type

Expiration Date

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

YesNo

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

YesNo

If the answer to either A or B is Yes, give details

Straight Truck Driving Experience

Experience
YesNo

Type of Truck

Approximate No. of Miles

Start Date

End Date

Additional Driving Experience

Experience
YesNo

Type

Approximate No. of Miles

Start Date

End Date

Other

Specify

Experience
YesNo

Type of Truck

Approximate No. of Miles

Start Date

End Date

List states operated in for last 5 years

Which safe driving awards do you hold and from whom?

Experience and Qualifications-Other

List any trucking, transportation, or other experience that may help in your work for this company

List courses and training other than shown elsewhere in this application

List special equipment of technical materials you can work with (other than those already shown)

Education

Highest Grade Completed

Last School Attended

To Be Read and Signed By Applicant

It is understood that this application will be given every consideration, but its receipt does not imply that the applicant will be employed. Any offer of employment from Falzones Towing Service, Inc is contingent on the applicant successfully passing a medical examination and a pre-employment drug screen.

I certify that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Signature

Date