CDL/DOT Application | All Finish Concrete

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Agreement

All Finish Concrete Co. is an at will employer.

Today's Date*

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 APPLICANT

Personal Information

Incomplete information could disqualify you from further consideration. Please complete all fields.

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone*

Email*

Position Applying For*

Rate of Pay Expected*

Drivers' Licenses

State*

License Number*

License Type*

Expiration Date*

State

License Number

License Type

Expiration Date

State

License Number

License Type

Expiration Date

Straight Truck

Class of Equipment

Type of Equipment

Dump, tank, flat, etc.

Approx. Number of Total Miles

Start Date

End Date

Tractor & Semi-Trailer

Class of Equipment

Type of Equipment

Dump, tank, flat, etc.

Approx. Number of Total Miles

Start Date

End Date

Tractor - Two Trailers

Class of Equipment

Type of Equipment

Dump, tank, flat, etc.

Approx. Number of Total Miles

Start Date

End Date

Other

Class of Equipment

Type of Equipment

Dump, tank, flat, etc.

Approx. Number of Total Miles

Start Date

End Date

Traffic Convictions & Forfeitures

Location of Incident

Incident Date

Charge

Penalty

Location of Incident

Incident Date

Charge

Penalty

No Traffic Convictions or Forfeitures in the past three years

Please initial box

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

Yes

No

Please provide details*

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

Yes

No

Please 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?*

Yes

No

Please give date and name of employer*

Accident Record for the Past Three Years

Date of Accident

Nature of Accident

Head on, rear end, etc.

Fatalities, Injuries, and/or Property Damage

Date of Accident

Nature of Accident

Head on, rear end, etc.

Fatalities, Injuries, and/or Property Damage

No Accidents in the past three years

Please initial box

To be Read & Signed by Applicant

Today's Date*

I 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

Past Employment Verification

Today's Date*

I 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 Signature

CDL/ DOT – Commercial Driver

Agreement

Personal Information

Residence

Drivers' Licenses

Straight Truck

Tractor & Semi-Trailer

Tractor - Two Trailers

Other

Traffic Convictions & Forfeitures

Accident Record for the Past Three Years

Employment History

To be Read & Signed by Applicant

Past Employment Verification

801 Christianson Dr W

Office: 218.287.1151

Fax: 701.566.5767

Residential Concrete

Commercial Concrete

Agricultural Concrete

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