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Equipment Operator Application 

Equipment Operator Application

Step 1 of 3

33%
Name
Address
MM slash DD slash YYYY
Are you applying as a CDL Driver?

YOUR HISTORY WITH ROAD WORX

Have you ever applied for a job with Road Worx, Inc. before?
Have you ever worked for Road Worx, Inc before?
Are you presently employed?
Do you have a friend or relative employed with us?
Are you legally able to be employed in the U.S.?
Do you have transportation to work?*
MM slash DD slash YYYY

EDUCATION HISTORY

List any technical/trade schools attended:
Other Education/Training/Certificates:

COMPLETE THE FOLLOWING SECTION FOR OFFICE/CLERICAL WORK

Typing
Words Per Minute:
Dictation
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?

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.
Address

Address

Address

Address

DRIVER HISTORY, EXPERIENCE, AND QUALIFICATIONS

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

ACCIDENT HISTORY

Please provide your accident record for the past three years or more.
MM slash DD slash YYYY

MM slash DD slash YYYY

TRAFFIC CONVICTIONS

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

TRAFFIC CONVICTION RECORD

Traffic convictions and forfeitures for past three years (other than parking violations).
MM slash DD slash YYYY

MM slash DD slash YYYY

DRIVER LICENSES

MM slash DD slash YYYY

MM slash DD slash YYYY

MM slash DD slash YYYY
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Has any license, permit or privilege ever been suspended or revoked?
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?
Have you ever been convicted of a felony?

DRIVING EXPERIENCE

Straight Truck

Tractor & Semi-Trailer

Other

Tractor - Two Trailers

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
Address

Name
Address

Name
Address

AUTHORIZATION TO OBTAIN MOTOR VEHICLE RECORD

Name
MM slash DD slash YYYY
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.
This field is for validation purposes and should be left unchanged.

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Locations in Knoxville, Nashville & Milan, Tennessee

865-765-0008 info@roadworxinc.com

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