EmailMe Form - Application for Employment Powell's Sanitation

Name *

Current Address *

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

How long at this address? *

Phone Number *

### - ### - ####

Email *

Date of Birth *

MM / DD / YYYY

Social Security Number *

Input numbers only, no dashes

Previous Three Years Residency #1 *

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

Number of years at this address *

Previous Three Years Residency #2 *

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

Number of years at this address *

Previous Three Years Residency #3 *

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

Number of years at this address *

LICENSE INFORMATION

Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license." I certify that I do not have more than one motor vehicle license, the information for which is listed below:

Motor Vehicle License Information *

State
License Number
Type
Expiration Date

DRIVING EXPERIENCE

(Enter 0 if a field does not apply.)

*

	Type of Equipment (Van, Tank, Flat, etc.)	Date - From	Date - To	Approx # of Miles (total)
Straight Truck
Tractor and Semi-Trailer
Tractor - Two Trailers
Other

Additional space, if needed

Accident Record for the Past 3 Years or More

	Date	Nature of Accident (Rear-End, Head-on, Upset)	Number Fatalities	Number Injuries	Chemical Spills? Yes or No
Accident 1
Accident 2
Accident 3

Additional space, if needed

Traffic Convictions and Forfeitures for the Past 3 Years (Other than Parking Violations)

	Date Convicted (Month/Year)	Violation	State of Violation Location	Penalty (Forfeited Bond, Collateral, and/or Points)
#1
#2
#3

Additional space, if needed

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

Yes

No

If yes, please explain:

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

Yes

No

If yes, please explain:

EMPLOYMENT RECORD

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).
NOTE: Must list the complete mailing address, street, city, state and zip code

Last Employer *

Employer Name
Address
Phone
Position Held
Dates (From - To)
Salary
Reason for Leaving
Any Gaps in Employment or Unemployment Must Be Explained. Include Dates (Month/Year) and Reason

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer? *

Yes

No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? *

Yes

No

Second Last Employer *

Employer Name
Address
Phone
Position Held
Dates (From - To)
Salary
Reason for Leaving
Any Gaps in Employment or Unemployment Must Be Explained. Include Dates (Month/Year) and Reason

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer? *

Yes

No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? *

Yes

No

Third Last Employer *

Employer Name
Address
Phone
Position Held
Dates (From - To)
Salary
Reason for Leaving
Any Gaps in Employment or Unemployment Must Be Explained. Include Dates (Month/Year) and Reason

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer? *

Yes

No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? *

Yes

No

Additional space, if needed

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make sure investigations and inquiries into 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 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 that I have the right to:
*Review information provided by current/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.

Signature of Applicant *

Clear

Date *

MM / DD / YYYY

This certifies that I completed this application, and all entries on it and information in it are true and complete to the best of my knowledge.

Signature of Applicant *

Clear

Date *

MM / DD / YYYY

NOTE: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.