Driver Application

Position:              Run:   

Personal Information

First Name        Middle Name         Last Name 

Address         

City            State               Zip code         

Phone #                        Cell Phone                  Social Security #     

Driver's License #        Issuing State        Expiration Date   

Date of Birth            Email Address  

Background Information

Driving Violations in the last 3 years?        Yes        No                        If yes, how many?   

Driving Accidents in the last 3 years?        Yes        No                        If yes, how many?   

Have you ever had a:    DWI?         Yes        No        DUI?         Yes        No      

Have you ever been convicted of a felony?         Yes        No      

Are you in Parole, Probation, or under suspended sentence for commission of a felony?

         Yes        No      

Have you ever pleaded guilty to, or been convicted of a criminal offence?

         Yes        No      If yes, how many years ago?   

Within the last THREE years, have you tested positive for a controlled substance, had an alcohol test

with an alcohol concentration of 0.04 or greater, or refused a required test for drugs or alcohol?

        Yes        No      

May we contact your current employer?            Yes        No       

Referred By:    

Work History

Please list as many previous employers as necessary to provide us with as least 3 years of employment

Current Employer

Name of Company        Job Title  

Phone #        City        State    

Dates of Employment

Reason for Leaving

2nd Most Recent Employer

Name of Company             Job Title   

Phone #       City        State   

Dates of Employment   

Reason for Leaving

3rd Most Recent Employer

Name of Company       Job Title   

Phone #        City        State   

Dates of Employment   

Reason for Leaving 

4th Most Recent Employer

Name of Company        Job Title   

Phone #        City        State   

Dates of Employment   

Reason for Leaving   

5th Most Recent Employer

Name of Company        Job Title   

Phone #        City        State   

Dates of Employment   

Reason for Leaving

6th Most Recent Employer

Name of Company        Job Title   

Phone #        City        State   

Dates of Employment   

Reason for Leaving

7th Most Recent Employer

Name of Company        Job Title   

Phone #        City        State   

Dates of Employment   

Reason for Leaving   

8th Most Recent Employer

Name of Company           Job Title   

Phone #        City        State   

Dates of Employment    

Reason for Leaving

PLEASE READ BEFORE COMPLETING THIS SURVEY

Employees are treated during employment without regard to race, color, religion, sex, national origin, age, veteran status, disability, or any other protected status.

As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Acton responsibilities where they  apply.

The purpose for this Data Survey is to comply with government record keeping, reporting, and other legal requirements. This data is for statistical analysis with respect to the success of the affirmative action program.  Periodic reports are made to the government on this information.  The completion of this data survey is optional.  If you choose to volunteer the requested information, please note that all Data Surveys are kept in a confidential file and are not part of your Application for Employment or personnel file. SUBMISSION OF THIS INFORMATION IS VOLUNTARY. INCLUSION OR

EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

VOLUNTARY SURVEY   

Sex:      Male          Female         Decline    

Check one of the Following: (Ethnic Origin)

White/Caucasian        Hispanic/Latino        American Indian/Alaskan Native

Black/African American         Asian        Native Hawaiian/ Pacific Islander

Other            Two or more races

 DECLINE TO FURNISH ETHNIC ORIGIN

Acknowledgement

   I understand that this Driver Internet Reference Form is a preliminary application and that if requested I will complete an Alan Ritchey, Inc. Driver Application for Employment. I further understand this Reference Form will be reviewed carefully, but its receipt does not imply that I will be employed.

  I certify that I personally completed this application and that all the information is true and correct. By submitting this application I authorize the release of all alcohol and controlled substance testing results pursuant to 382.2413 of the Federal Motors Carriers Safety Regulations and release this company from any and all liability as a result of providing the above information.

 

Please only click submit once!