Driver Application
Position: Select a position Mail Freight Tanker Truck Feed Mill Sand & Gravel HAZMAT Any Run: Select a run
Personal Information
First Name Middle Name Last Name
Address
City State Please choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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? (DOT and non-DOT reportable)
Yes No If yes, how many?
Have you ever had a: DWI? Yes No DUI? Yes No
Driver Endorsements? Hazmat Tanker Other None
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?
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 Please choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Dates of Employment
Reason for Leaving
2nd Most Recent Employer
3rd Most Recent Employer
4th Most Recent Employer
5th Most Recent Employer
6th Most Recent Employer
7th Most Recent Employer
8th Most Recent Employer
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.
Alan Ritchey, Inc.
DISCLOSURE AND RELEASE
For screening purposes:
I give my permission for Alan Ritchey, Inc. to contact my current employer.
I do not give my permission for Alan Ritchey, Inc. to contact my current employer until after I have been offered and I have accepted a position with the Company. I acknowledge that I may be terminated if information is discovered that would have disqualified me for the job if it had been known prior to my employment with Alan Ritchey, Inc.
In connection with my application for employment (including contract for services) with Alan Ritchey, Inc., I understand that consumer reports, which may contain public record information, may be requested from USIS Services, Tulsa, Oklahoma. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc., as well as information pertaining to my character, work habits, and performance. I further understand that such reports may contain public record information concerning my driving, credit, criminal, and civil records, from federal, state, and other agencies which maintain such records, as well as information from USIS concerning previous driving record requests made by others from such state agencies, and state provided driving records. In addition, I understand that Alan Ritchey Inc. participates in E-Verify to determine the eligibility of their employees to work in the United States. For more information on E-Verify, please go to http://www.dhs.gov/files/programs/gc_1185221678150.shtm.
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY USIS TO FURNISH THE ABOVE-MENTIONED INFORMATION.
I hereby certify that the information provided on this application is accurate to the best of my knowledge and subject to verification by this company. I authorize the company, its affiliates and their representatives to investigate all information given and to secure additional job-related information, if necessary. I authorize an investigative report to be made whereby information is obtained through personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors or others with whom I am acquainted. I understand and consent to an inquiry that may include information as to my character, general reputation, and personal characteristics, whichever may be applicable. This information may include, but is not limited to, verification of previous employment and employment references, verification of education including requests for transcripts, credit reports, motor vehicle driving records and criminal reports, etc. I hereby release from all liability or responsibility all persons, companies, organizations or corporations furnishing such information.
I understand that the information I have provided regarding my previous employment may be used, and my prior employers may be contacted for the purpose of investigating my background and safety performance history information as required by §391.23 (d) & (e) of the Federal Motor Carrier Safety Regulations.
Applicant’s signature (typed name)