Dot Application For Employment

Name in full

First Name:

Middle Name:

Last Name:

Phone Number:

Present Address

Number & Street:

City:

State:

Zip Code:

How Long?

Address for Past 3 years

Number & Street:

City:

State:

Zip Code:

How Long?

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Applying For Job as:

Full-Time Part-Time

Date Available:

Number of Years Experience

Salary Expected:

Is any additional information relative to change of name, use of assumed name, or nickname necessary to enable a check on the information you are providing on this form? If yes, please explain:

Can you, after employment, submit verification of your legal right to work in the United States?

Yes No

Date of Birth (DOT/CDL Required Only):

Social Security #:

Who do we notify in case of emergency during working hours?

Relationship:

Name:

Phone Number:

All Driver Licenses Held Last 3 Years

State:

License No.

Type:

Expiration Date:

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Dock, driving, yard and shop jobs may require physically agility and heavy exertion and lifting. Do you have any physical condition which may limit your ability to perform the job applied for?

Yes No

If yes, what can be done to accommodate your limitations?

Have you any relatives employed by this company?

Yes No

If yes, give names and Positions:

Have you ever worked for this Company before?

Yes No

Where?

When?

Are you employed now?

Yes No

If so may we inquire of your present employer?

Please list job-related organizations, clubs, professional societies; or other association to which you belong – you may omit those which indicate your race, religious creed, color, national origin, ancestry, gender, or age.

Have you ever been convicted of a felony?
(Such conviction will not necessarily disqualify you from the position applied for)

Yes No

Have you ever been convicted of a misdemeanor which resulted in imprisonment within the last two (2) years?
(Such conviction will not necessarily disqualify you from the position applied for)

Yes No

Education

High School

Name of School:

Address:

Graduate or Degree?

College or University

Name of School:

Address:

Graduate or Degree?

Business or Technical

Name of School:

Address:

Graduate or Degree?

Other

Name of School:

Address:

Graduate or Degree?

If you served in the military, list any skills learned which you feel are relevant to the position you are applying for:

The ability to be bonded is a condition for hire. A photograph and copy of your fingerprints may be required after employment.

References (Personal) Other Than Relatives

Name:

Address (Street-City-State)

Occupation:

Years Aquainted:

Name:

Address (Street-City-State)

Occupation:

Years Aquainted:

Previous Employment

(Give a complete record of all employment and reason for periods unemployed during the past 10 years. Start with your most recent employment)
(ATTACH SHEET IF MORE SPACE IS NEEDED)

Employer:

Address (Street-City-State)

Occupation:

Subject to FMCSR’s?*

Subject to 49 CFR Part 40?**

Employed From:

Employed To:

Reason for Leaving:

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* (10) (iv) (A) Applicant was subject to the Federal Motor Carrier Safety Regulations while employed by that previous employer.
** (10)(iv)(B)Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40.

Driving Experience Record

Class of Equipment:

Straight Truck

Type of Equipment (Van, Tank, Flat, etc)

Dates From:

Dates To:

Approx.No. of Miles (Total)

Class of Equipment:

Tractor and Semi-Trailer

Type of Equipment (Van, Tank, Flat, etc)

Dates From:

Dates To:

Approx.No. of Miles (Total)

Class of Equipment:

Tractor Two Trailers

Type of Equipment (Van, Tank, Flat, etc)

Dates From:

Dates To:

Approx.No. of Miles (Total)

Class of Equipment:

Other

Type of Equipment (Van, Tank, Flat, etc)

Dates From:

Dates To:

Approx.No. of Miles (Total)

Accident Record For Past 3 Years

(ATTACH SHEET IF MORE SPACE IS NEEDED)

Dates:

Last Accident

Nature of Accident (Head-On, Rear-End, Upset, etc.)

Fatalities:

Injuries:

Dates:

Next Previous

Nature of Accident (Head-On, Rear-End, Upset, etc.)

Fatalities:

Injuries:

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Traffic Convictions and Forfeitures for Past 3 Years (other than parking violations)

(ATTACH SHEET IF MORE SPACE IS NEEDED)

Location:

Date:

Charge:

Penalty:

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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, attach statement giving details.

General Driving Record

(ATTACH SHEET IF MORE SPACE IS NEEDED)

To date, I have driven trucks for years, covering approx. miles.

The date of my last accident while driving a commercial vehicle was since that time, I have driven approx. accident free miles.

Safe Driving Awards, etc.

Date:

Kind of Award:

Presented By:

While Employed By:

In Regonition of:

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Applicant: Read and Sign Before Submitting This Application

I authorize the employer or his agents to investigate my background to ascertain any and all information of concern to my record, whether same is of record or not, and release employers and persons named herein from all liability for any damages on account of his furnishing such information.

I understand that misrepresentation or omission of facts called for on this employment application will, if hired, result in discharge. Labor Code Section 2922 states that employment, having no specified term, may be terminated at the will at either party. The employer adheres to this section of the Labor Code and hereby puts the applicant on notice that all employment offered by the employer may be terminated at the will of either party without cause.

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:

Signature:

How did you hear about us?

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Dot Application For Employment

Name in full

Present Address

Address for Past 3 years

Who do we notify in case of emergency during working hours?

All Driver Licenses Held Last 3 Years

Education

References (Personal) Other Than Relatives

Previous Employment

Driving Experience Record

Accident Record For Past 3 Years

Traffic Convictions and Forfeitures for Past 3 Years (other than parking violations)

General Driving Record

Safe Driving Awards, etc.

Applicant: Read and Sign Before Submitting This Application

SAFETY PERFORMANCE HISTORY RECORDS REQUEST

Part 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

Hereby Authorize:

Arizona Materials, LLC

Part 2: TO BE COMPLETED BY PREVIOUS EMPLOYER (Accident History)

If There is NO Accident Register Data for This Driver.

Part 3: TO BE COMPLETED BY PREVIOUS EMPLOYER (Drug and Alcohol History)

Part 4: TO BE COMPLETED BY PREVIOUS EMPLOYER (Additional Information)

Part 5a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Part 5b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.