Applicant Name

Current Address

Previous Addresses

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.

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

    YesNo

    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

    Address

    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

    Address

    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

    Address

    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

    Accident #2

    Accident #3

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

    Traffic Conviction #1

    Traffic Conviction #2

    Traffic Conviction #3

    Experience and Qualifications-Driver

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

    Driver License

    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

    Straight Truck Driving Experience

    Experience
    YesNo
    Type of Truck

    Additional Driving Experience

    Experience
    YesNo
    Type

    Other

    Experience
    YesNo
    Type of Truck

    Experience and Qualifications-Other

    Education

    Highest Grade Completed

    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.