Bond Transfer Dispatcher Application

Application for Employment

Email:

Name:

Date:
Telephone Number

Current Address:

City: State: Zip:

*If at the above residence for less than three years, list below all residences for the past three years.

Street:

City: State: Zip:

Position Applying For:

Temporary Part Time
Full Time

Who referred you?

Expected pay rate:

Have you worked for this company before?

Dates:
From
To

Where?

Rate of pay:

Position:

Reason for leaving:

Phone Number:

Names of relatives employed by this company

Are you currently employed?

If not, how long since last employment?

EDUCATION:
Highest grade completed:

Last school attended:

Address:

GENERAL:
Have you ever worked for this company under another name?

If yes, what name(s)?

Have you ever been bonded?

Have you ever been convicted of a felony?

If yes attach details in comments section at bottom.

DRIVER EXPERIENCE & QUALIFICATION:
Answer the questions in this section only if applying for a driver position.

Date of Birth:
The U.S. Department of Transportation requires that driver applicants state their date of birth. (§391.21(b)(2))

Social Security Number: ex. ###-##-####

Drivers Licenses held in last 3 years must be shown:
Please include - State, License Number, Class, Endorsement(s), and Expiration 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?

C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?

If yes to any of the above 3, please enter details at the bottom of this page.

Driving Experience

Class of Equipment	Type of Equipment (Van, Flat, Tank, etc)	Dates		Approximate Total Miles
Class of Equipment	Type of Equipment (Van, Flat, Tank, etc)	From	To	Approximate Total Miles
Straight Truck
Tractor & Semi Trailer
Twin Trailers - LCV's
Other

List states operated in during in the last five years:

List special courses or training that will help you as a driver:

List driving awards held and who presented these awards:

Accident Review For Past Three Years

Nature of Accident(s)
(Head-on, rear-end, overturn, etc. Fatalities, injuries, etc.)

Traffic Convictions and Forfeitures for the past three years, other than parking violations

Location	Date	Charge	Penalty

EMPLOYMENT RECORD
The U.S. Department of Transportation requires that driver applications show all employment for the past three years. Those applying for a position requiring a CDL, must show employment history for 10 years prior to date of this application. §391.21(B)(10),(11)

Start with most recent or current position, including military experience, and work back.

Current Employer:
Full Address:
Position(s) Held: From: To: Salary: Supervisor's Full Name: Zip: Phone:
Reason for leaving:

Current Employer:
Full Address:
Position(s) Held: From: To: Salary: Supervisor's Full Name: Zip: Phone:
Reason for leaving:

PLATFORM EXPERIENCE & QUALIFICATIONS:

List types of platform experience and years each:

List platform equipment you can operate (lift truck, etc):

List courses or training in platform work:

APPLICANT MUST READ:

By Submitting, I certify that I have read and understood all of this employment application. It is agreed and understood that the employer or his agents may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons named herein from all liability for any damages on account of furnishing such information. I understand that as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the results of a physical examination and drug test.

I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.
I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of the employer.
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.

For Service Contact BOND