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Application for Employment


	APPLICATION FOR DRIVER DATE: _________________________ RTI(RECREATIONAL TRANSPORT INC.) 72506 ST RD 13 SYRACUSE IN 46567 574-457-2141 Name: ____________________________________ SS#__________________________ Address_______________________________________ How Long ________________ Address past 3 years: ______________________________________________________ Phone ________________________________ Date of birth:: _____________________ Drivers Lic#/State/Exp Date/Type:_¬¬¬¬¬¬¬__________________________________________ Emergency Contact Name: _________________________________________________ Contact Address: _________________________________________________________ Driving Experience: Type of Equip From dates to Approx#of miles ______________________________________________________ ______________________________________________________ ______________________________________________________ Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes or No Has any license, permit or privilege ever been suspended or revoked? Yes or No If you answered yes to either of the above 2 questions, attach a statement of explanation Accident Record for Dates Nature of Accident Injuries Fatalities Past 3 years: ____________________________________________ ____________________________________________ Traffic Convictions and forfeitures for past 3 years (other than parking violations) Location: Location Date Charge Penalty__________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ Education: Circle Highest grade completed: 1 2 3 4 5 6 7 8 High School 9 10 11 12 College: 1 2 3 4 ____________________________________________________________________ Name/City/State of high school or college Note: DOT requires that employment for at least 3 years and/or commercial driving experience for the past 10 years be shown Prior Work Experience (please list must recent 1st) Employer: _______________________________ Address: _____________________________ Position(duties): __________________________ Immediate Supervisor: __________________ Reason for leaving: _____________________________ Phone: __________________________ Were you subject to the FMCSRs while employed? Yes or No Was your job designed as a safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes or No Employer: _______________________________ Address: _____________________________ Position (duties): __________________________ Immediate Supervisor: __________________ Reason for leaving: _____________________________ Phone: __________________________ Were you subject to the FMCSRs while employed? Yes or No Was your job designed as a safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes or No Employer: _______________________________ Address: _____________________________ Position(duties): __________________________ Immediate Supervisor: __________________ Reason for leaving: _____________________________ Phone: __________________________ Were you subject to the FMCSRs while employed? Yes or No Was your job designed as a safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes or No Have you ever been convicted of, or pleaded guilty or nolo contendre (no contest) to a felony offense? Yes or No If yes, please provide: County/state in which felony occurred: ____________________________ DECLARATION OF EMPLOYMENT STATUS I understand that I must provide my complete employment history for the past 3 years, And all CDL required employment for the 7 years preceding that. Any gaps in employment longer than 1 month are explained as follows: From: _________________________ To: ____________________________ During this time, I was engaged in the following activity: ________________________________________________________________________________________________ In addition: ____________ I was not employed by a company or individual ____________ I was not convicted of any criminal act involving the use of a commercial motor vehicle or while driving a commercial motor vehicle TO BE READ AND SIGNED BY APPLICANT I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and MVR, and other related matters as may be necessary in arriving at an employment decision. (Generally inquires regarding medical history will be made only if and after a conditional offer of employment had been extended.) I hereby release employers, schools, health care providers and other person 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 interviews 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 employers 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 right to: • Review information provided by the 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 employers: 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. Signature: ____________ \| DRIVERS QUALIFICATIONS \| Application \| \| Return Home \| Our Services \| Driver Application \| Contact Us \|