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Employment Application Form

Employment Application Form

Position(s) Applied For*
Date of Application*
MM slash DD slash YYYY
FIrst Name*
First
Last Name*
Last
Social Security No.*
Email*
Phone*
List your addresses of residency for the past 3 years.
Current Address*
Street Address City State ZIP Code
How Long?
Previous Addresses
Street City State & Zip Code How Long?
Do you have the legal right to work in the U.S.?*
Date of Birth*
MM slash DD slash YYYY

(Required for commercial drivers)
Can you provide proof of age?*
Have you worked with this company before?*
Where?
Dates
From To Position
Reason for Leaving
Who referred you?
Rate of Pay Expected
Have you ever been bonded?
(Answer only if a job requirement.)
Name of Bonding Company
Can you perform, with or without reasonable accommodation, the essential functions of the job (as described in the job description)?*
Employment History
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle.

List employers in reverse order, starting with the most recent.
Employer 1
Employer 1 info A
Address City, State, Zip Contact Person Phone
Employer 1 info B
Position Held From (mo./yr.) To (mo./yr.) Reason for Leaving
Were you subject to the FMCSRs† while employed?
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?
Employer 2
Employer 2 info A
Address City, State, Zip Contact Person Phone
Employer 2 info B
Position Held From (mo./yr.) To (mo./yr.) Reason for Leaving
Were you subject to the FMCSRs† while employed?
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?
Employer 3
Employer 3 info A
Address City, State, Zip Contact Person Phone
Employer 3 info B
Position Held From (mo./yr.) To (mo./yr.) Reason for Leaving
Were you subject to the FMCSRs† while employed?
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?
Employer 4
Employer 4 info A
Address City, State, Zip Contact Person Phone
Employer 4 info B
Position Held From (mo./yr.) To (mo./yr.) Reason for Leaving
Were you subject to the FMCSRs† while employed?
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?
Employer 5
Employer 5 info A
Address City, State, Zip Contact Person Phone
Employer 5 info B
Position Held From (mo./yr.) To (mo./yr.) Reason for Leaving
Were you subject to the FMCSRs† while employed?
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?
Additional Past Employers
List any additional past employers in the space below...
* Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

† The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in Interstate commerce to transport passengrs or property when the vehicle: (1) weighs or has a GVWR of 10,001 lbs or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Have you had any accidents in the past 3 years?*
List all accidents, starting with the most recent:
Date Nature of Accident (head-on, rear-end, upset, etc) Fatalities Injuries Hazardous Material Spill
Have you had any Traffic Convictions or Forfeitures for the past 3 years (other than parking violations)?*
List all Traffic Convictions and Forfeitures for the past 3 years, starting with the most recent:
Location Date Charge Penalty
Experience and Qualifications - Driver
List all Driver Licenses and Permits held in the past 3 years:*
State License No. Class Endorsement(s) Exp. Date
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
B. Has any license, permit, or privilege ever been suspended or revoked?*
If the answer to either A or B is Yes, give details:
Driving Experience

Select Yes or No for each Class of Equipment below.
Straight Truck
Type of Equipment
Experience
Date From (mo./yr.) Date To (mo./yr.) Approx. No. of Miles (Total)
Tractor and Semi-Trailer
Type of Equipment
Experience
Date From (mo./yr.) Date To (mo./yr.) Approx. No. of Miles (Total)
Tractor - 2 Trailers
Type of Equipment
Experience
Date From (mo./yr.) Date To (mo./yr.) Approx. No. of Miles (Total)
Tractor - 3 Trailers
Type of Equipment
Experience
Date From (mo./yr.) Date To (mo./yr.) Approx. No. of Miles (Total)
Motorcoach - School Bus
(More than 8 passengers)
Experience
Date From (mo./yr.) Date To (mo./yr.) Approx. No. of Miles (Total)
Motorcoach - School Bus
(More than 15 passengers)
Experience
Date From (mo./yr.) Date To (mo./yr.) Approx. No. of Miles (Total)
Other Equipment
Description Date From (mo./yr.) Date To (mo./yr.) Approx. No. of Miles (Total)
List States Operated in Last 5 Years:
Describe any Special Courses or Training that will help you as a Driver:
Which Safe Driving Awards do you hold, and from whom?
Experience and Qualifications - Other
Describe any Trucking, Transportation, or Other Experience that may help you 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
Highest Grade Completed:*
Last School Attended:*
Name City, State
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 that 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 agrgee on the accuracy of the information.
Equal Opportunity Employer

Webb Concrete & Building Materials is an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals. In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, age disability, national or ethnic origin, military service status, citizenship, or other protected group status.
Certification*
I certify 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.*
Enter your full name:*
First Middle Last
Date:*
MM slash DD slash YYYY
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Email
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