APPLICATION FOR EMPLOYMENT

Date of Application: {field:date_1738939802910}

APPLICANT TO COMPLETE

Full Name: {field:full_name_last_first_middle_1715983498497}	Phone Number: {field:phone_number_1742647724238}	Social Security No: {field:social_security_number_1715983544176}
Positions Applied for: {field:position_s_applied_for_1715983467719}

{field:list_your_addresses_of_residency_for_the_past_3_years_1715984134588}

Do you have the legal right to work in the United States? {field:do_you_have_the_legal_right_to_work_in_the_united_states_1715984333211}
Date of birth: {field:date_of_birth_1715984362496}		Can you provide proof of age? {field:can_you_provide_proof_of_age_1715984402948}
Have you worked for this company before? {field:have_you_worked_for_this_company_before_1715984456292}		If so, where? {field:if_so_where_1715984532202}
From: {field:from_1715984548414}	To: {field:to_1715984558612}	Rate of Pay: {field:rate_of_pay_1715984578684}	Position: {field:position_1715984587787}
Reason for leaving: {field:reason_for_leaving_1715984596320}
Are you now employed? {field:are_you_now_employed_1715984609197}		If not, how long since leaving last employment: {field:if_not_how_long_since_leaving_last_employment_1715984632114}
Who referred you: {field:who_referred_you_1715984642959}		Rate of pay expected: {field:rate_of_pay_expected_1715984652811}
Have you ever been bonded? {field:have_you_ever_been_bonded_1715984701721}		Name of bonding company: {field:name_of_bonding_company_1715984723393}
Have you ever been convicted of a felony? {field:have_you_ever_been_convicted_of_a_felony_1715984862526}		If yes, please explain: {field:if_yes_please_explain_1715984888572}
Is there a reason you might be unable to perform the functions of the job for which you have applied (as described in the attached job description?){field:is_there_a_reason_you_might_be_unable_to_perform_the_functions_of_the_job_for_which_you_have_applied_as_described_in_the_attached_job_description_1715985018126}		If yes, explain if you wish: {field:if_yes_explain_if_you_wish_1715985044152}

EMPLOYMENT HISTORY

{field:employers_1715986230341}{field:html_1715985883390}

{field:accident_record_for_the_past_3_years_or_more_1738939883200}

{field:traffic_convictions_and_forfeitures_for_the_past_3_years_other_than_parking_violations_1715986419381}

EXPERIENCE AND QUALIFICATIONS - DRIVER

{field:list_all_driver_licenses_or_permits_in_the_past_3_years_1715986571243}

A. Have you ever been denied a license, permit, or priviledge to operate a motor vehicle? {field:a_have_you_ever_been_denied_a_license_permit_or_privilege_to_operate_a_motor_vehicle_1715986718970}	B. Has any license, permit, or priviledge ever been suspended?{field:b_has_any_license_permit_or_privilege_ever_been_suspended_1715986743683}
If the answer to either A or B is yes, give details: {field:if_the_answer_to_either_a_or_b_is_yes_give_details_1715986767071}

DRIVER EXPERIENCE

Class of Equipment	Type of Equiplment	From	To	Approx. No. of Miles Total
Straight Truck: {field:straight_truck_1715986878448}	{field:type_of_equipment_1715986905132}	{field:from_1715986941619}	{field:to_1715986951143}	{field:approximate_no_of_miles_total_1715986967442}
Tractor and Semi-Trailer: {field:tractor_and_semi_trailer_1715987099790}	{field:type_of_equipment_1715987104319}	{field:from_1715987109139}	{field:to_1715987113084}	{field:approximate_no_of_miles_total_1715987118726}
Tractor - Two Trailers: {field:tractor_-_two_trailers_1715987131929}	{field:type_of_equipment_1715987136042}	{field:from_1715987140566}	{field:to_1715987144037}	{field:approximate_no_of_miles_total_1715987149033}
Tractor - Three Trailers: {field:tractor_-_three_trailers_1715987168932}	{field:type_of_equipment_1715987177087}	{field:from_1715987185888}	{field:to_1715987193557}	{field:approximate_no_of_miles_total_1715987198501}
Motorcoach - School Bus (8+ Passengers): {field:motorcoach_-_school_bus_more_than_8_passengers_1715987250497}		{field:from_1715987212129}	{field:to_1715987215913}	{field:approximate_no_of_miles_total_1715987221016}
Motorcoach - School Bus (15+ Passengers): {field:motorcoach_-_school_bus_more_than_15_passengers_1715987241720}		{field:from_1715987255911}	{field:to_1715987283496}	{field:approximate_no_of_miles_total_1715987296919}
Ready-Mix Truck: {field:ready-mix_truck_1715987305857}	{field:type_of_equipment_1715987323780}	{field:from_1715987335465}	{field:to_1715987340729}	{field:approximate_no_of_miles_total_1715987344181}
Other: {field:other_1715987379944}	{field:type_of_equipment_1715987385107}	{field:from_1715987388085}	{field:to_1715987391115}	{field:approximate_no_of_miles_total_1715987394597}

List states operated in for the last five years: {field:list_states_operated_in_for_the_last_five_years_1715987534966}

Show special courses or training that will help you as a driver{field:show_special_courses_or_training_that_will_help_you_as_a_driver_1715987557266}

Which safe driving awards do you hold and from whom? {field:which_safe_driving_awards_do_you_hold_and_from_whom_1715987583570}

EXPERIENCE AND QUALIFICATIONS - OTHER

Show any trucking transportation or other experience that may help in your work for this company: {field:show_any_trucking_transportation_or_other_experience_that_may_help_in_your_work_for_this_company_1715987704613}

List special equipment or technical materials you can work with other than those already shown: {field:list_special_equipment_or_technical_materials_you_can_work_with_other_than_those_already_shown_1715987722804}

EDUCATION

Select highest grade completed: {field:select_highest_grade_completed_1715987780495}

Name of last school attended: {field:name_of_last_school_attended_1715987939505}

City: {field:city_1715987950231}

State: {field:state_1715987962107}

IN COMPLIANCE WITH FEDERAL AND STATE EQUAL EMPLOYMENT OPPORTUNITY LAWS, QUALIFIED APPLICANTS ARE CONSIDERED FOR ALL POSITIONS WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, MARITAL STATUS, VETERAN STATUS, NON-JOB RELATED DISABLITY, OR ANY OTHER PROTECTED GROUP STATUS.

I AUTHORIZE DICKINSON READY MIX ("DRM") TO MAKE SUCH INVESTIGATIONS AND INQUIRIES OF MY CONSUMER REPORTS OR INVESTIGATIVE CONSUMER REPORTS. THESE REPORTS MAY CONTAIN CONSUMER RECORDS, CRIMINAL RECORDS, DRIVING RECORDS, EDUCATIONAL RECORDS, PRIOR EMPLOYMENT RECORDS, MEDICAL HISTORY, AND OTHER PERSONAL OR RELATED MATTERS, AS MAY BE NECESSARY IN ARRIVING AT AN MPLOYMENT DECISION. I FURTHER AUTHORIZE ANY FORMER EMPLOYER, SCHOOL, POLICE DEPARTMENT, FINANCIAL INSTITUTION, DIVISION OF MOTOR VEHICLES, OR OTHER PERSONS OR AGENCIES HAVING KNOWLEDGE ABOUT ME TO FURNISH DRM WITH ANY AND ALL BACKGROUND INFORMATION ABOUT ME. (INQUIRIES REGARDING MEDICAL HISTORY WILL BE MADE ONLY IF AND AFTER A CONDITIONAL OFFER OF EMPLOYMENT HAS BEEN EXTENDED.) I HEREBY RELEASE EMPLOYERS, SCHOOLS, HEALTH CARE PROVIDERS AND OTHER PERSONS FROM ALL LIABILITY IN RESPONDING TO INQUIRIES AND RELEASING INFORMATION IN CONNECTION WITH MY APPLICATION.

I UNDERSTAND THAT I HAVE THE RIGHT TO MAKE A REQUEST FOR DRM, UPON PROPER IDENTIFICATION AND PAYMENT OF ANY LEGALLY PERMISSIBLE FEES, TO PROVIDE ME WITH THE INFORMATION IN ITS FILES RELATED TO ME AT THE TIME OF MY REQUEST.

I FURTHER UNDERSTAND THAT IF ADVERSE ACTION IS TAKEN WITH RESPECT TO ANY CONSUMER REPORT THAT IS BASED IN WHOLE OR IN PART ON ANY INFORMATION IN THE CONSUMER REPORT, DRM SHALL:

PROVIDE ME WITH ORAL, WRITTEN, OR ELECTRIC NOTICE AND THE BASIS OF THE ADVERSE ACTION;
PROVIDE ME WITH WRITTEN OR ELECTRONIC DISCLOSURE OF A NUMERICAL CREDIT SCORE AS DEFINED IN 15 USC 1681g(1)(2)(A) AND INFORMATION SET FORTH IN 15 USC 1681g(f)(1)(B) - (E);
PROVIDE ME WITH ORAL, WRITTEN, OR ELECTRONIC NOTICE OF THE NAME, ADDRESS, AND TELEPHONE NUMBER OF THE CONSUMER REPORTING AGENCY THAT FURNISHED THE REPORT AND A STATEMENT THAT THE CONSUMER REPORTING AGENCY DID NOT MAKE THE DECISION TO TAKE THE ADVERSE ACTION AND IS UNABLE TO PROVIDE A REASON WHY THE ADVERSE ACTION WAS TAKEN; AND
PROVIDE ME WITH ORAL, WRITTEN, OR ELECTRIC NOTICE OF MY RIGHT TO OBTAIN UNDER 15 USC 1681j, A FREE COPY OF A CONSUMER REPORT ON ME FROM THE CONSUMER REPORTING AGENCY PROVIDING THE CONSUMER REPORT, WHICH SHALL INCLUDE AN INDICATION OF THE 60 DAY PERIOD FOR OBTAINING SAID COPY AND MY RIGHT TO DISPUTE WITH A CONSUMER REPORTING AGENCY THE ACCURACY OR COMPLETENESS OF THE INFORMATION IN THE CONSUMER REPORT

I FURTHER UNDERSTAND THAT IF ADVERSE ACTION IS TAKEN WITH RESPECT TO ANY INFORMATION OBTAINED FROM THIRD PARTIES, OTHER THAN CONSUMER REPORTING AGENCIES, DRM SHALL:

PROVIDE ME WITH ORAL, WRITTEN, OR ELECTRIC NOTICE OF THE ADVERSE ACTION;
PROVIDE ME WITH ORAL, WRITTEN, OR ELECTRIC NOTICE THAT I MAY OBTAIN THE INFORMATION RECEIVED WHICH LEAD TO THE ADVERSE ACTION, UPON A WRITTEN REQUEST BY ME WHICH IS RECEIVED WITHIN 60 DAYS AFTER THE TRANSMITTAL OF THE NOTICE OF THE ADVERSE ACTION; AND
PROVIDE ME THE NATURE OF THE INFORMATION UPON WHICH THE ADVERSE ACTION IS BASED, NOT MORE THAN 30 DAYS AFTER DRM'S RECEIPT OF MY WRITTEN REQUEST

INTERVIEW(S) MAY IN THE EVENT OF EMPLOYMENT, I UNDERSTAND THAT FALSE OR MISLEADING INFORMATION GIVEN IN MY APPLICATION OR INTERVIEW(S) MAY RESULT IN DISCHARGE. I UNDERSTAND, ALSO, THAT I AM REQUIRED TO ABIDE BY ALL RULES AND REGULATIONS OF THE COMPANY.

I UNDERSTAND THAT INFORMATION I PROVIDE REGARDING CURRENT AND/OR PREVIOUS EMPLOYERS MAY BE USED, AND THOSE EMPLOYER(S) WILL BE CONTACTED, FOR THE PURPOSE OF INVESTIGATING MY SAFETY PERFORMANCE HISTORY AS REQUIRED BY 49 CFR 391.23 (d) AND (e). I UNDERSTAND I HAVE THE RIGHT TO:

REVIEW INFORMATION PROVIDED BY PREVIOUS EMPLOYERS;
HAVE ERRORS IN THE INFORMATION CORRECTED BY PREVIOUS EMPLOYERS AND FOR THOSE PREVIOUS EMPLOYER(S) TO RESEND THE CORRECTED INFORMATION TO THE PROSPECTIVE EMPLOYER; AND
HAVE A REBUTTAL STATEMENT ATTACHED TO THE ALLEGED ERRONEOUS INFORMATION, IF THE PREVIOUS EMPLOYERS) AND I CANNOT AGREE ON THE ACCURACY OF THE INFORMATION.

{field:i_agree_to_all_the_above_mentioned_terms_1715983380283}

TO BE READ AND SIGNED BY THE APPLICANT

This certifies that this application was completed by me, the applicant, and that all entries on it and information are true and complete to the best of my knowledge: {field:this_certifies_that_this_application_was_completed_by_me_the_applicant_and_that_all_entries_on_it_and_information_are_true_and_complete_to_the_best_of_my_knowledge_1715988108436}

Date: {field:date_1715988113923}

Employment Application