Employment Application - Stuckman Tree Service

Application for Employment

Applicant Information

Position(s) applied for

Hold Ctrl to select multiple positions

Name*

First

Middle

Last

SSN*

List your addresses of residency for the past 3 years.

Current Address

Street Address*

City*

State

Zip

Phone*

How Long?*

Previous Address

Street Address*

City*

State

Zip

How Long?*

Do you have the legal right to work in the United States*

yes

Date of Birth

Email address

Can you provide proof of age?

yes

Have you worked for this company before*

Yes

Where?

From

Position

Rate of Pay

Reason for leaving?

Are you now employed?

yes

If not, how long since leaving last employment?

Who referred you?

Rate of pay expected

Have you ever been bonded?

yes

(Answer only if a job requirement)

Name of bonding company

Have you ever been convicted of a felony?

yes

If answered yes above, please explain fully. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered

Is there any reason you might be unable to perform the function s of the job for which you have applied?

yes

If answered yes above, explain if you wish.

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 addictional 7 years' information on those employers for whom the applicant operated such vehicle. (Note: List employers in reverse order starting with the most recent. Add another sheet as necessary)

Employer 1

Name*

Address*

City*

State

Zip

Contact Person*

Phone Number*

Describe duties briefly*

Can we contact this employer?*

Yes

Start Date*

End Date*

Position*

Salary/Wage*

Reason for leaving

Were you subject to the FMCSRs† while employed?*

Yes

Was your job desinated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?*

Yes

Employer 2

Name*

Address*

City*

State

Zip

Contact Person*

Phone Number*

Describe duties briefly*

Can we contact this employer?*

Yes

Start Date*

End Date*

Position*

Salary/Wage*

Reason for leaving

Were you subject to the FMCSRs† while employed?*

Yes

Was your job desinated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?*

Yes

Employer 3

Name*

Address*

City*

State

Zip

Contact Person*

Phone Number*

Describe duties briefly*

Can we contact this employer?*

Yes

Start Date*

End Date*

Position*

Salary/Wage*

Reason for leaving

Were you subject to the FMCSRs† while employed?*

Yes

Was your job desinated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?*

Yes

Employer 4

Name*

Address*

City*

State

Zip

Contact Person*

Phone Number*

Describe duties briefly*

Can we contact this employer?*

Yes

Start Date*

End Date*

Position*

Salary/Wage*

Reason for leaving

Were you subject to the FMCSRs† while employed?*

Yes

Was your job desinated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?*

Yes

Employer 5

Name*

Address*

City*

State

Zip

Contact Person*

Phone Number*

Describe duties briefly*

Can we contact this employer?*

Yes

Start Date*

End Date*

Position*

Salary/Wage*

Reason for leaving

Were you subject to the FMCSRs† while employed?*

Yes

Was your job desinated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?*

Yes

Employer 6

Name*

Address*

City*

State

Zip

Contact Person*

Phone Number*

Describe duties briefly*

Can we contact this employer?*

Yes

Start Date*

End Date*

Position*

Salary/Wage*

Reason for leaving

Were you subject to the FMCSRs† while employed?*

Yes

Was your job desinated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?*

Yes

*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 passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, () 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.

Accident Record

For past 3 years or more

Date

Nature of accident

Fatalities

Injuries

Hazardous Mat Spill

Date

Nature of accident

Fatalities

Injuries

Hazardous Mat Spill

Date

Nature of accident

Fatalities

Injuries

Hazardous Mat Spill

Traffic Convictions

and forfeitures for past 3 years or more (other than parking violations) if none, leave blank.

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

Experience and Qualifications - Driver

List all driver licenses or permits held in the past 3 years

State

License No.

Type

Exp. Date

State

License No.

Type

Exp. Date

State

License No.

Type

Exp. Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes

B. Has your license, permit or privilege ever been suspended or revoked?*

Yes

If the answer to either A or B is yes, give details.

Experience and Qualifications - Driver

Straight Truck

yes

Type of equipment

van

tank

flat

dump

refer

From

Approx # of Miles (total)

Tractor & Semi-trailer

yes

Type of equipment

van

tank

flat

dump

refer

From

Approx # of Miles (total)

Tractor - Two trailers

yes

Type of equipment

van

tank

flat

dump

refer

From

Approx # of Miles (total)

Tractor - Three trailers

yes

Type of equipment

van

tank

flat

dump

refer

From

Approx # of Miles (total)

Motorcoach - School bus

yes

More than 8 passengers

From

Approx # of Miles (total)

Motorcoach - School bus

yes

More than 15 passengers

From

Approx # of Miles (total)

Other

Type of equipment

From

Approx # of Miles (total)

List states operated in for last five years:

Show 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

Show any trucking, transportation or other experience that may help 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

(May or may not be considered depending on the job applied for).

Check highest grade completed

High School

College

Last school attended

To be read and signed by applicant

Please read carefully and sign below

This certifies 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

Print Name

Sign below (required)

Clear

Signature*

Date

This field should be left blank