General Information
Date of Application:
Position(s) Applied for:
First Name:
Social Security #:
Middle Initial:
Home Phone:
Last Name:
E-Mail:
Address:
City:
State:
Zip:
Address for past three years
Address 1:
How Long?
Address 2:
How Long?
How did you hear about us?
How did you hear about us:
If from an employee, who?
Employment Questions
Do you have the legal right to work in the United States?
Choose
Yes
No
Are you over the age of 18?
Choose
Yes
No
Have you worked for this company before?
Choose
Yes
No
If you worked for us before, please indicate when and what position.
Are you employed now?
Choose
Yes
No
If not, how long since leaving last employment?
Who referred you?
Rate of pay expected:
Have you ever been convicted of a felony?
Choose
Yes
No
If yes, explain below. Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.
Is there any reason you might be unable to perform the functions of the job for which you have applied
Employment History (Employment information for the past 3 years.)
Current/Recent Employer:
Address:
City/State/Zip:
Telephone:
From:
To:
Position Held:
Reason For Leaving:
Second Employer:
Address:
City/State/Zip:
Telephone:
From:
To:
Position Held:
Reason For Leaving:
Third Employer:
Address:
City/State/Zip:
Telephone:
From:
To:
Position Held:
Reason For Leaving:
Fourth Employer:
Address:
City/State/Zip:
Telephone:
From:
To:
Position Held:
Reason For Leaving:
Military Status
Have you served in the U.S. Armed Forces?
Choose
Yes
No
Branch:
Education
Please indicate highest grade completed:
Last School Attended (Name and City):
Experience and Qualifications - Driver
Driver Licenses
State
License No.
Type
Experation Date
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Choose
Yes
No
B. Has any license, permit or privilege ever been suspended or revoked?
Choose
Yes
No
C. If the answer to either of these questions was Yes, please explain below.
Driving Experience
Class of Equipment Type of Equipment Dates (From, To) Approx. Number of Miles (Total or Time)
Straight Truck
Tractor and Semi-Trailer
Tractor-Two Trailers
Forklift
List states operated in for last five years:
Show special courses or training that will help you as a driver:
Which safe driving awards do you hold and from whom?
Accident Record for past 3 years or more
Any accidents?
Choose
Yes
No
If YES, answer the following questions.
1) What Year:
Fatalities:
Injuries:
Nature of Accident (Head-on, Rear-end, Upset, etc.)
2) What Year:
Fatalities:
Injuries:
Nature of Accident (Head-on, Rear-end, Upset, etc.)
3) What Year:
Fatalities:
Injuries:
Nature of Accident (Head-on, Rear-end, Upset, etc.)
Traffic convictions or forfeitures for past 3 years (besides parking violations)
1) Location:
Date:
Charge:
Penalty:
2) Location:
Date:
Charge:
Penalty:
3) Location:
Date:
Charge:
Penalty:
Experience and Qualifications - Platform
List types of platform experience and years of each:
List platform equipment you can operate (lift truck, etc.)
List any other experience that may help in your work for this company:
TO BE READ AND ELECTRONICALLY SIGNED BY APPLICANT
This certifies 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. I authorize you to make such investigations and inquireies 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 I am required to abide by all rules and regulations of the Company.
Date:
Applicant's Name/Signature:
Part II - Consumer Report and Investigative Consumer Report Disclosure (For Employment Purposes)
In connection with your employment or application for employment (including contract for services) and in accordance with applicable laws, USIS may obtain or assemble consumer reports and/or investigate consumer reports (collectively, "Reports") which may include information about you related to: previous employment (including employers, dates of employment, salary information, reasons for termination, etc.), accident history, academic history, verification of references and other information supplied by applicant, professional credentials, drug/alcohol use in violation of law and/or company policy, dirving records, information about your character, general reputation, personal characteristics and mode of living (collectively, "Information"). Information may be optained from government agencies, educational institutions, USIS clicnets, personal references, personal interviews, and other Information suppliers (collectively, "Suppliers").
Choose
Yes
No
Indicate YES or NO if you are applying for employment in California and/or you are a California resident and, in either case, you wish to receive a copy of your credit report or investigative consumer report if one is obtained or assembled by USIS. Pursuant to the California Civil Code, you may view the file maintained on you by USIS during normal business hours. You may also obtain a copy of this file by submitting proper identification and paying applicable costs for such file, if required by law, by contacting USIS in person or by mail. SUIS is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.
Choose
Yes
No
Indicate YES or NO if you are applying for employment in Oklahoma and/or you are an Oklahoma resident and, in either case, you wish to receive a copy of your consumer report if one is obtained or assembled by USIS.
Choose
Yes
No
Indicate YES or NO if you are applying for employment in Minnesota and/or you are a Minnesota resident and, in either case, you wish to reeive a copy of your consumer report if one is obtained or assembled by USIS.
Part II - Authorization for Release of Information (For Employment Purposes)
I hereby authorize USIS to receive Information and disclose such Information to its customers for the purpose of making a determination as to my eligibility for employment, promotion, retention or other lawful purpose. If hired or contracted, I authorize USIS and the USIS customer named above ("Customer") to retain this document on file to act as ongoing authorization for the procurement and possession of Reports at any time during my employment or contract period. I fully release USIS and Suppliers from all claims of damages related to the investigation of my background and provision of Information as set forth in this disclosure and authorization. I agree that Information is USIS's possession and my employment history with Customer if I am hired, may be supplied by USIS to other USIS customers for legally permissible purposes; provided, such Information will not include the Drug and Alcohol information set forth in Part I above, unless I have given a seperate specific consent for USIS to share such Information.Note - This Authorization Does Not Apply To Drug and Alcohol Info, Addressed in Part I.
Applicant Name/Signature:
Social Security #:
Date:
