Employment | Rogers Landworks

COMPLETE IN FULL OR IT WILL NOT BE CONSIDERED

Applicant Information:

First Name:

Middle Name:

Last Name:

Phone:

Email:

Date of Birth:

Social Security #:

Date of Application:

Position Applied for:

Date Available for Work:

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

Yes

No

Previous Three Years Residency:

Current

Street

City

State

Zip Code

# of Years at Address

Mailing

Street

City

State

Zip Code

# of Years at Address

Previous

Street

City

State

Zip Code

# of Years at Address

Previous

Street

City

State

Zip Code

# of Years at Address

Previous

Street

City

State

Zip Code

# of Years at Address

License Information:

No person who operates a commercial motor vehicle shall at any time have more than one drivers's license (49 CFR 383.21). I Certify that I do not have more than one motor vehicle license, the Information for which is listed below. Include all licenses held for the past 3 years.

Current

State

License #

Type/Class

Endorsements

Expiration Date

Previous

State

License #

Type/Class

Endorsements

Expiration Date

Previous

State

License #

Type/Class

Endorsements

Expiration Date

Driving Experience:

Straight Truck

Type of Equipment (VAN, TANK, FLAT, etc.)

Date From

Date To

Approx # of Miles (Total)

Tractor & Semi-Trailer

Type of Equipment (VAN, TANK, FLAT, etc.)

Date From

Date To

Approx # of Miles (Total)

Tractor & 2 Trailers

Type of Equipment (VAN, TANK, FLAT, etc.)

Date From

Date To

Approx # of Miles (Total)

Tractor & Tanker

Type of Equipment (VAN, TANK, FLAT, etc.)

Date From

Date To

Approx # of Miles (Total)

Others

Type of Equipment (VAN, TANK, FLAT, etc.)

Date From

Date To

Approx # of Miles (Total)

Accident Record for the Past 3 Years:

Check this box if none

1. Date

Nature of Accident (Head-on, rear-end, upset, etc.)

# Fatalities

# Injuries

Chemical Spills?

Yes

No

2. Date

Nature of Accident (Head-on, rear-end, upset, etc.)

# Fatalities

# Injuries

Chemical Spills?

Yes

No

3. Date

Nature of Accident (Head-on, rear-end, upset, etc.)

# Fatalities

# Injuries

Chemical Spills?

Yes

No

Traffic Convictions and Forfeitures for the Past 3 Years (Other than parking violations)

Check this box if none

1. Date Convicted

Violation

State of Violation

Penalty (forfeited bond, collateral and/or points)

2. Date Convicted

Violation

State of Violation

Penalty (forfeited bond, collateral and/or points)

3. Date Convicted

Violation

State of Violation

Penalty (forfeited bond, collateral and/or points)

4. Date Convicted

Violation

State of Violation

Penalty (forfeited bond, collateral and/or points)

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

Yes

No

If yes, explain

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

Yes

No

If yes, explain

Employment History:

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. If you have driven a commercial vehicle previously, you must provide employment history for an additional seven(7) years (for a total of then(10) years). Any gaps in employment in excess of one(1) month must be explained.

Start with the last or current position, Including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, Including street number, city, state, zip and complete all other information.

1. Employer:

Phone Number

Address

Position Held:

Dates of Employment

From:

To:

Reason for Leaving

Salary

Explain any gaps in employment (Include moth/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes

No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes

No

2. Employer:

Phone Number

Address

Position Held:

Dates of Employment

From:

To:

Reason for Leaving

Salary

Employment any gaps in employment (Include moth/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes

No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes

No

3. Employer:

Phone Number

Address

Position Held:

Dates of Employment

From:

To:

Reason for Leaving

Salary

Employment any gaps in employment (Include moth/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes

No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes

No

Education History:

High School

Location

Course of Study

Year Completed

Graduate

Yes

No

Details

College

Location

Course of Study

Year Completed

Graduate

Yes

No

Details

Other

Location

Course of Study

Year Completed

Graduate

Yes

No

Details

Other Qualifications

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