Non-Driver's Application - Doug Bradley Trucking

Applicant Name

Date of Application

Email

Application for:
Doug Bradley Trucking, Inc.
680 E. Water Well Rd.
Salina, KS 67401

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 I am required to abide by all rules and regulations of the Company.

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 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.
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.

Signature *

Typing your name in this field constitutes your signature

Date *

Today's Date

APPLICANT TO COMPLETE
(answer all questions)

Position(s) Applied for *

List your addresses of residency for the past 3 years

Current Address

Street *

City *

State *

Zip *

Phone *

How Long *

yr./mo.

Previous Addresses

Street

City

State

Zip

How Long

yr./mo.

Street

City

State

Zip

How Long

yr./mo.

Street

City

State

Zip

How Long

yr./mo.

Do you have the legal right to work in the United States? *

Yes

No

Have you worked for this company before? *

Yes

No

If so, where?

Date: From

Date: To

Rate of Pay

Position

Are you now employed? *

Yes

No

If not, how long since leaving last employment?

Who referred you?

Rate of pay expected:

Have you ever been bonded?

Yes

No

(Answer only if a job requirement)

Name of Bonding Company

(if applicable)

Have you ever been convicted of a felony? *

Yes

No

If yes, please explain fully

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? *

Yes

No

If yes, explain if you wish

Employment History

All applicants must provide the following information on all employers during the preceding 10 years. List complete mailing address, street number, city, state, and zip code.

Employer Name

Address

City

State

Zip

Contact Person

Phone

From

Mo. / Yr.

To

Mo. / Yr.

Position Held

Salary / Wage

Reason for Leaving

Employer Name

Address

City

State

Zip

Contact Person

Phone

From

Mo. / Yr.

To

Mo. / Yr.

Salary / Wage

Position Held

Reason for Leaving

Employer Name

Address

City

State

Zip

Contact Person

Phone

From

Mo. / Yr.

To

Mo. / Yr.

Salary / Wage

Position Held

Reason for Leaving

Employer Name

Address

City

State

Zip

Contact Person

Phone

From

Mo. / Yr.

To

Mo. / Yr.

Salary / Wage

Position Held

Reason for Leaving

Employer Name

Address

City

State

Zip

Contact Person

Phone

From

Mo. / Yr.

To

Mo. / Yr.

Salary / Wage

Position Held

Reason for Leaving

Employer Name

Address

City

State

Zip

Contact Person

Phone

From

Mo. / Yr.

To

Mo. / Yr.

Salary / Wage

Position Held

Reason for Leaving

DRIVERS LICENSE

List all driver licenses or permits held in the past 3 years

State *

License No. *

Type *

Expiration *

Mo. / Yr.

State

License No.

Type

Expiration

Mo. / Yr.

State

License No.

Type

Expiration

Mo. / Yr.

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

Yes

No

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

Yes

No

IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS

Experience and Qualifications - Other

Show Special Courses or Training that will help you:

Show any experience that may help in your work for this company

List courses and training other than shown elsewhere in this application

List Special Equipment or Technical Materials you can work with (other than those already shown)

Education

Select Highest Grade Completed

High School

1

2

3

4

College

1

2

3

4

Last School Attended

School Name

City / State

TO BE READ AND SIGNED BY APPLICANT

I understand that typing my name in the signature field constitutes my electronic signature. 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.

Signature *

Date *

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