Email us at : info@jessdiaztrucking.com REQUEST A QUOTE CALL US NOW FOR YOUR TRANSPORT +1 (714)522-4800 SERVICES ABOUT US JOBS CONTACT US JOB APPLICATION JOB APPLICATION COMMERCIAL DRIVER APPLICATION APPLICANT INFORMATION DATE Position applying for: Contractor Driver Contractor's Driver NAME PHONE EMERGENCY PHONE AGE DATE OF BIRTH SS# (The Age Discrimination of 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.) PHYSICAL EXAM EXPIRATION DATE CURRENT & PREVIOUS THREE YEARS ADDRESSES FROM TO FROM TO FROM TO HAVE YOU WORKED FOR THIS COMPANY BEFORE? Yes No IF YES, GIVE DATES: FROM TO EDUCATION HISTORY: PLEASE SELECT THE HIGHEST GRADE COMPLETED: GRADE SCHOOL: 1 2 3 4 5 6 7 8 9 10 11 12 COLLEGE: 0 1 2 3 4 POST GRADUATE: 0 1 2 3 4 EMPLOYMENT HISTORY: Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years. MO/YR MO/YR PRESENT OR LAST EMPLOYER FROM TO NAME POSITION HELD ADDRESS REASON FOR LEAVING COMPANY PHONE WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED HERE? Yes No 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? Yes No MO/YR MO/YR PRESENT OR LAST EMPLOYER FROM TO NAME POSITION HELD ADDRESS REASON FOR LEAVING COMPANY PHONE WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED HERE? Yes No 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? Yes No MO/YR MO/YR PRESENT OR LAST EMPLOYER FROM TO NAME POSITION HELD ADDRESS REASON FOR LEAVING COMPANY PHONE WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED HERE? Yes No 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? Yes No MO/YR MO/YR PRESENT OR LAST EMPLOYER FROM TO NAME POSITION HELD ADDRESS REASON FOR LEAVING COMPANY PHONE WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED HERE? Yes No 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? Yes No MO/YR MO/YR PRESENT OR LAST EMPLOYER FROM TO NAME POSITION HELD ADDRESS REASON FOR LEAVING COMPANY PHONE WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED HERE? Yes No 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? Yes No MO/YR MO/YR PRESENT OR LAST EMPLOYER FROM TO NAME POSITION HELD ADDRESS REASON FOR LEAVING COMPANY PHONE WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED HERE? Yes No 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? Yes No MO/YR MO/YR PRESENT OR LAST EMPLOYER FROM TO NAME POSITION HELD ADDRESS REASON FOR LEAVING COMPANY PHONE WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED HERE? Yes No 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? Yes No DRIVING EXPERIENCE CLASS OF EQUIPMENT FROM TO APPROX # OF MILES STRAIGHT TRUCK TRACTOR & SEMI-TRAILER TRACTOR & TWO TRAILERS TRACTOR & TRIPLE TRAILERS OTHER LIST STATES OPERATED IN FOR THE LAST FIVE (5) YEARS LIST SPECIAL COURSES/TRAINING COMPLETED (PTD/DDC, HAZMAT, ETC) LIST ANY SAFE DRIVING AWARDS YOU HOLD AND FROM WHO ACCIDENT RECORD FOR PAST THREE (3) YEARS DATE OF ACCIDENT NATURE OF ACCIDENTS (HEAD ON, REAR END, ETC) LOCATION OF ACCIDENT # OF FATALITIES # OF PEOPLE INJURED TRAFFIC CONVICTIONS AND FORFEITURES FOR THE LAST THREE (3) YEARS (OTHER THAN PARKING VIOLATIONS) DATE LOCATION CHARGE PENALTY DRIVER'S LICENSE (LIST EACH DRIVER'S LICENSE HELD IN THE PAST THREE (3) YEARS STATE LICENSE TYPE ENDORSEMENTS EXPIRATION DATE HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE? HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED? IS THERE ANY REASON YOU MIGHT BE UNABLE TO PERFORM THE FUNCTIONS OF THE JOB FOR WHICH YOU HAVE APPLIED (AS DESCRIBED IN THE JOB DESCRIPTION)? HAVE YOU EVER BEEN CONVICTED OF A FELONY? IF THE ANSWERS TO ANY QUESTIONS LISTED ABOVE ARE "YES", GIVE DETAILS JOB REFERENCES LIST THREE (3) PERSONS FOR REFERENCES, OTHER THAN FAMILY MEMBERS, WHO HAVE KNOWLEDGE OF YOUR SAFETY HABITS NAME ADDRESS PHONE NAME ADDRESS PHONE NAME ADDRESS PHONE TO BE READ AND SIGNED BY APPLICANT It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain 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 an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my application file. It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I 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. APPLICANT SIGNATURE DATE CONTACT US JESS DIAZ TRUCKING P.O. Box 367 La Mirada, CA 90637-0367 Phone : (714) 522-4800 Email : Info@JessDiazTrucking.com JESS DIAZ TRUCKING Jess Diaz Trucking, Inc has been in operation since 1976, specializing in hauling general freight, including corrugated cartons, paper product, and machinery. We transport freight in the states of California, Nevada and Arizona. Copyright 2016. All Rights Reserved by Jess Diaz Trucking