CDL/DOT Application Application for Employment: Commercial Driver In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex (including pregnancy), national origin, age, marital status, veteran status, non-job-related disability, genetic information or any other protected group status. Step 1 of 10 10% AgreementAll Finish Concrete Co. is an at will employer.I authorize All Finish Concrete Co. Inc. to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, 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. 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 All Finish Concrete. 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 that I have a right to: • Review information provided by previous employers • Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information*TO BE READ AND SIGNED BY APPLICANTToday's Date* Date Format: MM slash DD slash YYYY Personal InformationIncomplete information could disqualify you from further consideration. Please complete all fields.Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* SSN*Position Applying For*Rate of Pay Expected* ResidenceLast three yearsAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Months / Years*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Months / YearsAre you eligible to work in the United States?*YesNoAre you at least 18 years or older?*YesNoCan you provide proof of age?*YesNoHave you ever been employed by All Finish before?*YesNoPlease describe your previous position with All Finish Concrete and the dates you were employed along with reason for leaving:*Are you now employed?*YesNoHow long since leaving last employment?*Have you ever been convicted of a felony?*YesNoPlease explain crime conviction fully in the space provided:*Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation?*YesNo Drivers' LicensesState*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense Number*License Type*Expiration Date* Date Format: MM slash DD slash YYYY StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense NumberLicense TypeExpiration Date Date Format: MM slash DD slash YYYY StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense NumberLicense TypeExpiration Date Date Format: MM slash DD slash YYYY Straight TruckClass of EquipmentType of EquipmentDump, tank, flat, etc.Start Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Approx. Number of Total MilesTractor & Semi-TrailerClass of EquipmentType of EquipmentDump, tank, flat, etc.Start Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Approx. Number of Total MilesTractor - Two TrailersClass of EquipmentType of EquipmentDump, tank, flat, etc.Start Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Approx. Number of Total MilesOtherClass of EquipmentType of EquipmentDump, tank, flat, etc.Start Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Approx. Number of Total Miles Traffic Convictions & ForfeituresLocation of IncidentIncident Date Date Format: MM slash DD slash YYYY ChargePenaltyLocation of IncidentIncident Date Date Format: MM slash DD slash YYYY ChargePenaltyNo Traffic Convictions or Forfeitures in the past three yearsPlease initial boxHave you ever been denied a license, permit or privilege to operate a motor vehicle?*YesNoPlease provide details*Has any license, permit or privilege ever been suspended or revoked?*YesNoPlease provide details*Have you ever tested positive or refused to be tested on a Pre-Employment Drug Screen for an employer that you did not go to work for?*YesNoPlease give date and name of employer* Accident Record for the Past Three YearsDate of Accident Date Format: MM slash DD slash YYYY Nature of Accidenthead on, rear end, etc.Fatalities, Injuries, and/or Property DamageDate of Accident Date Format: MM slash DD slash YYYY Nature of Accidenthead on, rear end, etc.Fatalities, Injuries, and/or Property DamageNo Accidents in the past three yearsPlease initial box Employment HistoryInclude your last seven (7) years of employment history, including periods of unemployment, starting with the most recent and working backwards in time. Incomplete information could disqualify you from further consideration.Company 1*Phone*Address* Street Address City State / Province / Region ZIP / Postal Code Employment Start* Date Format: MM slash DD slash YYYY Employment End* Date Format: MM slash DD slash YYYY Supervisor* First Last Job Title*Responsibilities*Reason for Leaving*Were you subjected to the FMCSRs+ while employed?*YesNoWas your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?*YesNoCompany 2PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Employment Start Date Format: MM slash DD slash YYYY Employment End Date Format: MM slash DD slash YYYY Supervisor First Last Job TitleResponsibilitiesReason for LeavingWere you subjected to the FMCSRs+ while employed?YesNoWas your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?YesNoCompany 3PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Employment Start Date Format: MM slash DD slash YYYY Employment End Date Format: MM slash DD slash YYYY Supervisor First Last Job TitleResponsibilitiesReason for LeavingWere you subjected to the FMCSRs+ while employed?YesNoWas your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?YesNo To be Read and Signed by ApplicantI understand that a copy of my Motor Vehicle Record and the information in this application, including past employment information, will be used and that prior employers will be contacted for purposes of investigating my safety performance history information as required by paragraphs (d) and (e) of Part 391.23 of the Federal Motor Carrier Safety Regulations. I also understand that I have the following rights regarding the investigative information that will be provided to All Finish Concrete: 1) the right to review information provided by previous employers; 2) the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to All Finish Concrete; 3) the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and I cannot agree on the accuracy of the information. In order to review previous employer-provided investigative information I must submit a written request to All Finish Concrete, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. All Finish Concrete will provide this information to me within five business days of receiving my written request. If All Finish Concrete has not yet received the requested information from the previous employer(s), then the five-business days’ deadline will begin when All Finish Concrete receives the requested safety performance history information. If I have not arranged to pick up or receive the requested records within thirty (30) days of All Finish Concrete making them available, All Finish Concrete may consider me to have waived my request to review the records. I also understand that misrepresentation or omission of information or facts may results in my rejection or dismissal. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.*Applicant's Electronic Signature Today's Date* Date Format: MM slash DD slash YYYY Past Employment VerificationI hereby authorize all previous employers to release records of my employment, including assessment of my job performance, commercial driving, accidents, general work ability/fitness and drug & alcohol history to All Finish Concrete. I hereby release this company from any and all liability as a result of providing the requested information to All Finish Concrete. I also understand that I have the following rights regarding the investigative information that will be provided to All Finish Concrete: 1) the right to review information provided by previous employers; 2) the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to All Finish Concrete; 3) the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and I cannot agree on the accuracy of the information. In order to review previous employer-provided investigative information I must submit a written request to All Finish Concrete, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. All Finish Concrete will provide this information to me within five business days of receiving my written request. If All Finish Concrete has not yet received the requested information from the previous employer(s), then the five-business day deadline will begin when All Finish Concrete receives the requested safety performance history information. If I have not arranged to pick up or receive the requested records within thirty (30) days of All Finish Concrete making them available, All Finish Concrete may consider me to have waived my request to review the records. I also, understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.*Applicant's SignatureToday's Date* Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
