CDL/DOT Application – All Finish Concrete

Agreement
All 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 APPLICANT
Today's Date*
MM slash DD slash YYYY

Personal Information
Incomplete 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*
Position Applying For*
Rate of Pay Expected*

Drivers' Licenses
State*
License Number*
License Type*
Expiration Date*
MM slash DD slash YYYY
State
License Number
License Type
Expiration Date
MM slash DD slash YYYY
State
License Number
License Type
Expiration Date
MM slash DD slash YYYY

Straight Truck
Class of Equipment
Type of Equipment

Dump, tank, flat, etc.
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Approx. Number of Total Miles
Tractor & Semi-Trailer
Class of Equipment
Type of Equipment

Dump, tank, flat, etc.
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Approx. Number of Total Miles
Tractor - Two Trailers
Class of Equipment
Type of Equipment

Dump, tank, flat, etc.
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Approx. Number of Total Miles
Other
Class of Equipment
Type of Equipment

Dump, tank, flat, etc.
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Approx. Number of Total Miles

Traffic Convictions & Forfeitures
Location of Incident
Incident Date
MM slash DD slash YYYY
Charge
Penalty
Location of Incident
Incident Date
MM slash DD slash YYYY
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
MM slash DD slash YYYY
Nature of Accident
head on, rear end, etc.
Fatalities, Injuries, and/or Property Damage
Date of Accident
MM slash DD slash YYYY
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 and Signed by Applicant
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
Today's Date*
MM slash DD slash YYYY

Past Employment Verification
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
Today's Date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Application for Employment: Commercial Driver

Step 1 of 10

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 and Signed by Applicant

Past Employment Verification