APPLICATION FOR EMPLOYMENT
Customer One Towing 348 E. Cullumber Ave. Gilbert, Az
Phone 480-786-3300 Fax 480-786-0459
The purpose of this application is to determine whether or not the applicant is qualified to operate Motor Carrier Equipment according to the Federal Motor Carrier Safety Regulations and Customer One Towing
Instructions: Please answer all questions. If the answer to any question is “No” or “None” please indicate
The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.
Date:_______________________
Name: __________________________________
Social Security # __________________________
Age: _______ Date of Birth: _________________
Home Phone: _____________________Cell Phone: ______________
Current Address:
_______________________________________________________
Three Years Previous Addresses:
______________________________________________________ ______________________________________________________ ______________________________________________________
Are there any days or nights that you can not work? Please specify: ________________________________________________________________
This is a
Driving Experience
Class of Equipment From To Approx # of Miles
Straight Truck
Tractor and Semi-Trailer
Other
List states operated in for the last five years:
Show special courses or training that will help you as a driver:
What safe driving awards do you hold and from whom? ________________________________________________________________
Accident Record for the past three years (attach sheet if more space is needed)
Dates Nature of Accident (head on, rear end, etc.) # of Fatalities # of Injuries
Traffic Convictions & Forfeitures for the last three years (other than parking violations)
Location Date Charge Penalty
Driver’s License (list each driver’s license held in the past three years)
State License # Type Endorsements Expiration Date
EMPLOYMENT HISTORY
Give a complete record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past 10 years
Month / Year Month / Year Present or Last Employer
From____________ To____________ ____________________________
Supervisor: ___________________________ _____________________
Position Held: _________________________ Salary: _______________
Reason for Leaving:________________________________________________
Month / Year Month / Year Present or Last Employer
From____________ To____________ ____________________________
Supervisor: ___________________________ _____________________
Position Held: _________________________ Salary: _______________
Reason for Leaving:________________________________________________
Month / Year Month / Year Present or Last Employer
From____________ To____________ ____________________________
Supervisor: ___________________________ _____________________
Position Held: _________________________ Salary: _______________
Reason for Leaving:________________________________________________
PERSONAL REFERENCES
List three persons for reference, other than relatives, who have knowledge of your safety habits
Name: ____________________________ Phone: ____________________
Address: ___________________________ Relation: ___________________
Name: ____________________________ Phone: ____________________
Address: ___________________________ Relation: ___________________
Name: ____________________________ Phone: ____________________
Address: ___________________________ Relation: ___________________
Please supply us with a copy of the following documents:
Drivers License – Social Security Card – Medical Card – MVR report at time of interview
If you are hired, you will be required to take a pre-employment drug screen
TO BE READ & SIGNED BY APPLICANT
It is agreed and understood that any misrepresentation given above shall be considered an act of dishonesty
It is agreed and understood that the motor carrier and his agents may investigate the applicants background to ascertain any and all information of concern to applicant’s record, whether same 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 91-508 I have been told that this investigation may include information regarding my character, general reputation, personal characteristics and mode of living.
I agree and to furnish such additional information and complete such examinations as may be required to complete my employment file.
It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ the applicant.
It is agreed and understood that if qualified the driver may be on a probationary period during which time he 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 the best of my knowledge.
Date: ___________________ Applicant Signature: _______________________