Equipment Operator Application

Step 1 of 3

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Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Drivers License Number

Drivers License Expiration Date

MM slash DD slash YYYY

Are you applying as a CDL Driver?

Yes! I have a CDL and am applying for a position that involves driving a Commercial Motor Vehicle

YOUR HISTORY WITH ROAD WORX

Have you ever applied for a job with Road Worx, Inc. before?

Yes

If yes, when?

Have you ever worked for Road Worx, Inc before?

Yes

Position

Pay Rate

Dates

Reason for leaving

Are you presently employed?

Yes

If not, how long since leaving last employment?

Do you have a friend or relative employed with us?

Yes

If yes, who?

Are you legally able to be employed in the U.S.?

Yes

Do you have transportation to work?*

Yes

On what date will you be available for work?

MM slash DD slash YYYY

Wage/Salary Required:

EDUCATION HISTORY

Highest grade completed in grade school:

Highest grade completed in high school:

How many years in college:

List any technical/trade schools attended:

Special Skills:

Other Education/Training/Certificates:

COMPLETE THE FOLLOWING SECTION FOR OFFICE/CLERICAL WORK

Typing

Yes

Words Per Minute:

Dictation

Yes

Words Per Minute:

Computer Skills:

Please list other skills and/or equipment/language experience you have acquired:

MILITARY RECORD

Have you ever served in the military?

Yes

Branch of service:

Present military affiliation:

Kinds of training and duty while in service.

JOB HISTORY

Starting with present or most recent, give a complete record of all employment including any unemployment or self-employment for the past 3 years. Per 49 CFR 391.21 (b)(11), drivers applying to operate a commercial motor vehicle (CDL Drivers) must provide employment records for the past 10 years.

Company name and type of business:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type or classification of job:

Job duties:

Dates worked:

Reason for leaving:

Were you subject to the FMSCR's while employed with this company?

Was your position considered a safety sensitive function in any DOT-regulated mode subject to controlled substance and alcohol testing?

Company name and type of business:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type or classification of job:

Job duties:

Dates worked:

Reason for leaving:

Were you subject to the FMSCR's while employed with this company?

Was your position considered a safety sensitive function in any DOT-regulated mode subject to controlled substance and alcohol testing?

Company name and type of business:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type or classification of job:

Job duties:

Dates worked:

Reason for leaving:

Were you subject to the FMSCR's while employed with this company?

Was your position considered a safety sensitive function in any DOT-regulated mode subject to controlled substance and alcohol testing?

Company name and type of business:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type or classification of job:

Job duties:

Dates worked:

Reason for leaving:

Were you subject to the FMSCR's while employed with this company?

Was your position considered a safety sensitive function in any DOT-regulated mode subject to controlled substance and alcohol testing?

DRIVER HISTORY, EXPERIENCE, AND QUALIFICATIONS

Have you had any auto accidents in the past three years?(Required)

Yes

ACCIDENT HISTORY

Please provide your accident record for the past three years or more.

Date of most recent accident:

MM slash DD slash YYYY

Nature of accident. (Head-on, Rear-end, Upset, etc.)

Injuries?

Fatalities?

Date of next previous accident:

MM slash DD slash YYYY

Nature of accident. (Head-on, Rear-end, Upset, etc.)

Fatalities?

Injuries?

TRAFFIC CONVICTIONS

Have you had any traffic convictions or forfeitures in the past three years?

Yes

TRAFFIC CONVICTION RECORD

Traffic convictions and forfeitures for past three years (other than parking violations).

Location

Date

MM slash DD slash YYYY

Charges

Penalties

Location

Date

MM slash DD slash YYYY

Charges

Penalties

DRIVER LICENSES

State:

License Number:

Type:

Expiration Date:

MM slash DD slash YYYY

State:

License Number:

Type:

Expiration Date:

MM slash DD slash YYYY

State:

License Number:

Type:

Expiration Date:

MM slash DD slash YYYY

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

Yes

If yes, please explain.

Has any license, permit or privilege ever been suspended or revoked?

Yes

If yes, please explain.

Have you ever tested positive or refused a DOT controlled substance (drug) or alcohol pre-employment test within the past two years from an employer who did not hire you?

Yes

If yes, please explain.

Have you ever been convicted of a felony?

Yes

If yes, please explain.

DRIVING EXPERIENCE

Straight Truck

Type (Dump, Van, Tank, Flat, etc.)

Dates

Approx. # of total miles

Tractor & Semi-Trailer

Type (Dump, Van, Tank, Flat, etc.)

Dates

Approx. # of total miles

Other

Type (Dump, Van, Tank, Flat, etc.)

Dates

Approx. # of total miles

Tractor - Two Trailers

Type (Dump, Van, Tank, Flat, etc.)

Dates

Approx. # of total miles

List states operated in for the past 5 years:

List any Safe Driving Awards you earned, and from whom:

List special courses and/or training completed (HazMat, PTD/DDC, etc.):

REFERENCES

Please provide three references other than relatives or former employers.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Business & Title

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Business & Title

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Business & Title

AUTHORIZATION TO OBTAIN MOTOR VEHICLE RECORD

Name

First Last

Date of Birth:

MM slash DD slash YYYY

Driver's License #:

State Issuing License:

Upload your resume here:

Max. file size: 64 MB.

AUTHORIZATION

I certify that this application was completed by me and the facts contained in this application are true and complete to the best of my knowledge and understand that falsified or misleading statements on this application shall be grounds to deny my application or, if employed, to terminate my employment. I also understand that incomplete responses may result in the denial of my application or, if employed, the termination of my employment. Note to Drivers of Commercial Motor Vehicles (CDL Drivers): Making fraudulent or intentionally false statements or records is a violation of 49 CFR 390.95 and is subject to federal penalty by the Federal Motor Carrier Safety Administration. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have. I understand that this application is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract of employment. I further understand that if I am hired, my employment will be AT WILL and that either party may terminate the employment relationship at any time, without prior notice and for any or no reason. I also understand and agree that no representative of the company has any authority to alter the at will relationship or enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the forgoing, unless it is in writing and signed by the President of Road Worx, Inc. and me.

Please enter your name below as a digital signature.

Phone

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