Fayetteville Contractors, Inc. APPLICATION FOR EMPLOYMENT P.O. Box 610 CDL License Fayetteville, PA 17222-0610 Equal Opportunity Employer 717-352-2186 Date It is the policy of Fayetteville Contractors, Inc. that all applicants are treated without regard to their age, race, color, creed, national origin, religion, disability, veteran status, gender and/or other protected status. Home (Middle) (Maiden, if any) (Last) Cell How long? Date of Birth Social Security Number Current Driver’s License No A B C Endorsements H N Address for the past three years if different from above (Attach sheet if more space is needed) How long? How long? Would you take a physical examination? Job for with you are applying Wage expected Applying for: Full time work No Part time work Yes No Are you presently employed? Yes No If yes, may we contact your employer Yes No Have you had any special training in any job classification or vocation? If Yes, explain List three references (list no more than one relative) Address Address Address Experience and Qualifications - Driver Driver License License No. Class/Endorsements Expiration Date Driving Experience Class of Equipment Type of Equipment (Van, Flat, Dump, Etc.) Dates From To Approx. No. of Miles (Total) Straight Tractor & Tractor – Two Trailers Other Accident Record for past 3 years or more (attach sheet if more space is needed). If none, please indicate NONE. Nature of Accident (Head-on, rear-end, upset, etc.) Fatalities Injuries Traffic Convictions and Forfeitures for the past 3 years (other than parking violations) Date Location Charge Penalty Attached if more space is needed
Fayetteville Contractors, Inc. APPLICATION FOR EMPLOYMENT P.O. Box 610 CDL License Fayetteville, PA 717-352-2186 Applicant’s Name 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 you have answered A or B with Yes, Explain Employment Record Note: Federal Motor Carrier Safety Regulations (FMCSR(s)) and U.S. Department of Transportation (DOT) requires that employment for at least 3 years and/or Commercial Driving experience for the past 10 years be shown (attached if additional space is needed). Most recent employer Name: (Street) (City) & Zip Code) Position Held From To Reasons for Leaving Were you subject to the FMCSR’s while employed by previous employer? Yes No Was job designated as a safety sensitive function subject to alcohol and controlled substances testing requirements as required by 49CFR Part 40? Yes No Second last employer Name: Phone (Street) (City) (State & Zip Code) Position Held From To Reasons for Leaving Were you subject to the FMCSR’s while employed by previous employer? Yes No Was job designated as a safety sensitive function subject to alcohol and controlled substances testing requirements as required by 49CFR Part 40? Yes No Third last employer Name: Phone (Street) (City) (State & Zip Code) Position Held From To Reasons for Leaving Were you subject to the FMCSR’s while employed by previous employer? Yes No Was job designated as a safety sensitive function subject to alcohol and controlled substances testing requirements as required by 49CFR Part 40? Yes No