785.628.1485 - 800.782.5647 | Ask Us About Our Free Estimates | hproofing@hproofing.com Home Roofing Systems Employment Contact Us If you are interested in employment with High Plains Roofing, please fill out the application bellow or if you would rather print out and send the application to our Hays office, please click the link bellow. – Print Application – Application For Employment High Pains Roofing Inc. 1710 E. 10th Street Hays, Kansas 67601 | 785.628.1485 | Your Contact Info Your Name Phone Number Email Address Time At This Address DOB/SSN PREVIOUS THREE RESIDENCY 1) 2) 3) LICENSE INFORMATON Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license, the information for which is listed below. DRIVING EXPERIENCE Class of Equipment | | Type of Equipment (Van, Tank, Flat, etc.) || Dates (From - To) | | Approx. # of Total Miles Straight Truck Tractor and Semi-Trailer Tractor - Two Trailers Other Equipment ACCIDENT RECORD FOR PAST 3 YEARS Chemical Spill Yes No Chemical Spill Yes No Chemical Spill Yes No TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS A. Have you ever been denied a license, permit or privilege to operate a moter vehicle? Yes No If Yes, explain: B. Has any license, permit or privilege ever been suspeded or revoked? Yes No If Yes, explain: EMPLOYMENT RECORD Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record). Must list the complete mailing address: street number and name, city, state and zip code. Last Employer Name: Position Held: From To Salary Reason For Leaving: Any Gaps In Employment and/or Unemployment Must Be Explained. Include Dates (Month/Year) and Reason: Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohal and controlled substances testing requirements as required b 49 CFR Part 40? Yes No Second Last Employer Name: Position Held: From To Salary Reason For Leaving: Any Gaps In Employment and/or Unemployment Must Be Explained. Include Dates (Month/Year) and Reason: Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohal and controlled substances testing requirements as required b 49 CFR Part 40? Yes No Third Last Employer Name: Position Held: From To Salary Reason For Leaving: Any Gaps In Employment and/or Unemployment Must Be Explained. Include Dates (Month/Year) and Reason: Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohal and controlled substances testing requirements as required b 49 CFR Part 40? Yes No To Be Read And Signed By Applicant I authorize you to make sure investingations and inquiries to 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 hearby 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 undersand 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 that I have the right to: Review information provided by current/previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-send the correct 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 I copleted this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations. Submit Design by DelRay Dreiling | Open Eye Dezign |