Transportation Company
995 E. Daniel Drive
Mt Vernon MO
Phone: (417) 466-3700 / Fax (417) 466-7993

Employment Application

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Personal Information

Last Name:

First Name:

Middle Name:

Social Security Number:

Street Address

City

State & Zip code

Phone number:

Date of Birth

Email Address:

In case of emergency notify:

Emergency phone number:

Emergency Address:

Position Desired:

Have you ever applied here before?
Yes
No

When?
From:
To:
Position:

Reason for leaving:

Are you currently employed?
Yes
No

If not, how long since last employment?

If you were referred,
by whom?

Previous Residences

Previous Addresses:

How Long:

1

2

3

Education

Have you attended truck driving school?

Yes
No

If so, enter School's name, address and date started and graduation date:

Highest Grade Completed:

Please enter any other schools you've attended:

Graduated?

Yes
No

Please enter any degrees, honors, clerical or mechanical skills you have:

Military Status

Have you served in the Armed Forces?

Yes
No

If so,

Branch:
From: to

Are you currently a member of the Active Reserves or the National Guard?

Yes
No

Enter any special skills that you received:

Employment History
Begin with your most recent employment

Current Employer's name, address and phone number and supervisor's name:

Position Held:

Date Employed
From: to

Are you currently working for this employer? Yes No

May we contact this employer? Yes No

Number of Accidents:
Number of Service Failures:
Number of States driven in:

Were you ever suspended or reprimanded for any violation of Company or DOT rules, regulations or policies? Yes No

Were you ever placed on probation? Yes No

 

Second Last Employer's name, address and phone number and supervisor's name:

Position Held:

Date Employed
From: to

Number of Accidents:
Number of Service Failures:
Number of States driven in:

Were you ever suspended or reprimanded for any violation of Company or DOT rules, regulations or policies? Yes No

Were you ever placed on probation? Yes No

 

Third Last Employer's name, address and phone number and supervisor's name:

Position Held:

Date Employed
From: to

Number of Accidents:
Number of Service Failures:
Number of States driven in:

Were you ever suspended or reprimanded for any violation of Company or DOT rules, regulations or policies? Yes No

Were you ever placed on probation? Yes No

 

Fourth Last Employer's name, address and phone number and supervisor's name:

Position Held:

Date Employed
From: to

Number of Accidents:
Number of Service Failures:
Number of States driven in:

Were you ever suspended or reprimanded for any violation of Company or DOT rules, regulations or policies? Yes No

Were you ever placed on probation? Yes No

 

Fifth Last Employer's name, address and phone number and supervisor's name:

Position Held:

Date Employed
From: to

Number of Accidents:
Number of Service Failures:
Number of States driven in:

Were you ever suspended or reprimanded for any violation of Company or DOT rules, regulations or policies? Yes No

Were you ever placed on probation? Yes No

 

Sixth Last Employer's name, address and phone number and supervisor's name:

Position Held:

Date Employed
From: to

Number of Accidents:
Number of Service Failures:
Number of States driven in:

Were you ever suspended or reprimanded for any violation of Company or DOT rules, regulations or policies? Yes No

Were you ever placed on probation? Yes No

 

Seventh Last Employer's name, address and phone number and supervisor's name:

Position Held:

Date Employed
From: to

Number of Accidents:
Number of Service Failures:
Number of States driven in:

Were you ever suspended or reprimanded for any violation of Company or DOT rules, regulations or policies? Yes No

Were you ever placed on probation? Yes No

 

Driver's Experience

Type

Length of Experience

Approx Mileage

Straight truck

Tractor & Semi Trailer

Others

License

Have you ever been charged / convicted of driving under the influence of alcohol or a controlled substance?

No
Yes Date:
Please explain:

Has your license or privilege to drive ever been suspended or revoked?

No
Yes Date:
Please explain:

 

Have you ever been convicted of any misdemeanor other than a traffic violation?

No
Yes Date:
Please explain:


 

Have you ever been convicted of a felony?

No
Yes Date:
Please explain:

 

Please list all driver's licenses that you presently hold or have held in the past 3 years:

License No 1:
Lic No:
State:
Endorsements:
Exp Date:

License No 2:
Lic No:
State:
Endorsements:
Exp Date:

License No 3:
Lic No:
State:
Endorsements:
Exp Date:

License No 4:
Lic No:
State:
Endorsements:
Exp Date:

Accidents

List all accidents in the past five years. Failure to list all may disqualify this application. Omit if you've had no accidents in the past five years.

Date: Veh Type:
 Whose Fault:
Injuries (other than self):
Dollar Amount of Damage:
Please describe:

 

Date: Veh Type:
 Whose Fault:
Injuries (other than self):
Dollar Amount of Damage:
Please describe:

Date: Veh Type:
 Whose Fault:
Injuries (other than self):
Dollar Amount of Damage:
Please describe:

Date: Veh Type:
 Whose Fault:
Injuries (other than self):
Dollar Amount of Damage:
Please describe:

Traffic Violations
I certify that the following list is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeit bond or collateral during the past five years. Failure to list all traffic violations may result in your disqualification. If you have had no traffic violations in the past five years, enter "NONE" (Any type of vehicle).

Traffic Conviction(s)
Describe:

Date of
violation

City and State where
violation occurred

If speeding, was
it over 15 mph over?

1

 

 

 
No
Yes

 

2

 

 

 
No
Yes

 

3

 

 

 
No
Yes

 

4

 

 

 
No
Yes

 

5

 

 

 
No
Yes

 

6

 

 

 
No
Yes

 

7

 

 

 
No
Yes

 

8

 

 

 
No
Yes

 

9

 

 

 
No
Yes

 

10

 

 

 
No
Yes

 

Agreement
Please read the following statements carefully

 This application is not an offer of employment. An offer of employment MAY BE made at a later date if the information supplied to New Rising Fenix, Inc. by yourself, past employees, government agencies and consumer reporting services is verified, and you meet all the qualifications for a professional truck driver as outlined by the Department of Transportation and New Rising Fenix, Inc.

I understand that New Rising Fenix, Inc. follows the practice of requiring driver applicants to successfully complete a company physical, which includes a drug and/or alcohol test, as a term and condition of qualification and from time to time thereafter to submit to a drug and/or alcohol test, upon company request, as a term and condition of continued qualification. Therefore, I hereby knowingly and freely give me consent to submit to a company physical, including a drug and/or alcohol test, and further agree to submit to a drug and/ or alcohol test when so requested by New Rising Fenix, Inc. I understand that my inability to successfully complete, or refusal to take, a company physical examination, including a drug and/or alcohol test would be cause for denial of qualification or disqualification, if qualified.

 I further authorize New Rising Fenix, Inc.'s Medical Review Officer to release the identity of any drugs for which I tested positive to New Rising Fenix, Inc. or examination physician. This authorization is provided to enable the company to notify me of the identity of such drugs as required by 49 CFR Section 391.87(b)(2). I further authorize New Rising Fenix, Inc. to release any Breath Alcohol, or any other approved DOT method for obtaining alcohol results to qualifying reporting agencies or prospective employers.

In connection with my application for qualification with New Rising Fenix, Inc., I understand that an investigative consumer report will be requested that will include information as to my character, work habits, performance and experience, along with reasons for termination of past employment obtained from previous employers. Further, I understand that New Rising Fenix, Inc. will be requesting information concerning my driving record and/or information from various federal and/or state agencies which maintains records concerning traffic offenses, accidents, etc. as well as information concerning (1) previous driving record requests made by others from such state and/or federal agencies and (2) accidents involving me in the files of insurance companies. I further understand that an investigative consumer report will be requested, such report may contain public record information concerning my driving record, worker's compensation claims, credit, bankruptcy proceedings, criminal history record, etc. from federal, state and other agencies. I have a right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I hereby consent to your obtaining the above described information, and agree that such information, and my experience history with New Rising Fenix, Inc., if I am qualified, will be supplied to other companies which subscribe to consumer reporting services. I further authorize my past employers and others contacted to answer all questions asked by New Rising Fenix, Inc. concerning my ability, character, reputation, alcohol and controlled substance testing results and/or refusal to take such tests to New Rising Fenix, Inc., I release all such persons and New Rising Fenix, Inc. from any liability on account of furnishing such information to New Rising Fenix, Inc. I authorize, without reservation, any party or agency contacted by New Rising Fenix, Inc. and/or investigative consumer reporting agencies to furnish the above mentioned information.

If qualified by New Rising Fenix, Inc., I further consent to New Rising Fenix, Inc. furnishing to consumer reporting agencies information concerning my character, work habits, performance, driving record and experience, drug and alcohol tests or refusal to take such tests as specified in 49 CFR 382, as well as any reasons for termination of my qualification, and further consent to these services furnishing such information in the future to other companies which subscribe to these services from which I am seeking employment, and to insurance companies or their agents in connection with issuance or maintenance of insurance coverage.

I understand that my employment, if any, can be terminated, with or without cause, at any time at the discretion of New Rising Fenix, Inc. or myself.

In accordance with Section 391.23 and Section 382 of the Federal Motor Carrier Safety Regulations, I authorize any and all persons and/or institutions to provide any relevant information that may be required to complete my qualifications.

If employed, I agree to familiarize myself, and adhere to, company policies, rules and procedures.

If employed, I understand that I am employed on a three-month probationary basis, that I may be terminated during this period at the discretion of New Rising Fenix, Inc.

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. I also agree that falsified information or significant omissions may result in my disqualification now or at any time.

I further certify that I am a genuine applicant for employment and that this application is being submitted for the purpose of seeking employment with New Rising Fenix, Inc. and for no other reason.

By clicking this Submit button, I stipulate that I have read and understand the above agreement.