Application for Employment - Edko, LLC



Application for Employment

PLEASE PRINT

Position(s) applied for___________________________________________________ Date of Application ____/__/____

Referral Source □ Advertisement □ Employee □ Relative □ Government Employment Agency

□ Walk-in □ Private Employment Agency □ Other ______________________

Name of Source (If Applicable) ______________________________________________________

Name ___________________________________________________________________________________________

Last First Middle

Address _________________________________________________________________________________________

Street City State Zip Code

Telephone Number (_____)_______________________________ Social Security Number _______-____-__________

If necessary, best time to call you at home is …………………………………………………. _________________________

May we contact you at work? ............................................................................................................................. □ Yes □ No

am

If yes, work number and best time to call ………………………………………………… (____)_____________ : _____ pm

If you are under 18, can you furnish a work permit? ………………………………………………………………… □ Yes □ No

Have you filed an application here before? …………………………………………………………………………... □ Yes □ No

If yes, give dates ………………………………………………………………………………………._______/_______/_______

Have you ever been employed here before? …………………………………………………................................. □ Yes □ No

If yes, give dates ………………………………………………………………………………...From _______/_______/_______

Are you legally eligible for employment in this country? …………………………………………………………….. □ Yes □ No

(Proof of U.S. Citizenship or immigration status will be required upon employment.)

Date available for work ……………………………………………………………………………… _______/_______/_______

Type of employment desired □ Full Time □ Part Time/Temporary/Seasonal

Are you on lay-off and subject to recall? ..…………………………………………………………………………... □ Yes □ No

Will you relocate if job requires it? ………… □ Yes □ No Will you travel if job requires it? ……………… □ Yes □ No

Are you able to meet the attendance requirements of the position? …………………………………………….. □ Yes □ No

Will you work overtime if required? ……………………………………………………………………………………. □ Yes □ No

Have you ever been bonded? ………………………………………………………………………………………….. □ Yes □ No

Have you been convicted or plead guilty to a felony in the last seven (7) years? ............................................ □ Yes □ No

(Such conviction may be relevant if job related, but does not bar you from employment.)

If yes, please explain: _____________________________________________________________________________

_______________________________________________________________________________________________

TO BE READ AND SIGNED BY APPLICANT

I authorize Edko 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, inquires 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 any 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 Edko.

“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 CFT 391.23(d) and 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

• 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__________________________________________________________________________ Date ________________________________

Employment History

(Ask for Additional Employment History form if needed) All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years; you must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total 10 year employment record).

CURRENT OR LAST EMPLOYER: Name: _________________________________Phone Number (____) __________

Position Held _____________________________________ Immediate Supervisor & Title ______________________

Dates Employed from ____________ to ______________ Hourly Rate/Salary Starting ________Final _____________

Summarize the nature of work performed ______________________________________________________________

Reasons for Leaving ______________________________________________________________________________

Were you subject to the FMCSRs ** while employed? □ Yes □ No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Par 40? □ Yes □ No Explain any gaps in employment ______________________________________________________________________________________________

SECOND LAST EMPLOYER: Name: ____________________________________ Phone Number (____) __________

Street Address __________________________ City ________________ State __________ Zip _________________

Position Held _______________________________________ Immediate Supervisor & Title ____________________

Date Employed From _______________ to ___________ Hourly Rate/Salary Starting __________ Final ___________

Were you subject to the FMCSRs ** while employed? □ Yes □ No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Par 40? □ Yes □ No Explain any gaps in employment

_______________________________________________________________________________________________

THIRD LAST EMPLOYER: Name: ____________________________________ Phone Number (____) ____________

Street Address __________________________ City ________________ State __________ Zip _________________

Position Held _______________________________________ Immediate Supervisor & Title ____________________

Date Employed From _______________ to ___________ Hourly Rate/Salary Starting __________ Final ___________

Were you subject to the FMCSRs ** while employed? □ Yes □ No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Par 40? □ Yes □ No Explain any gaps in employment

_______________________________________________________________________________________________

USE THIS SHEET FOR ADDITIONAL EMPLOYMENT HISTORY INFORMATION

Company: ________________________________________ Supervisor’s Name: ______________________________

Address: _____________________________________________________________ Phone: ( ) _______________

Position Held : ________________________________________From: _________ To: _________ Salary: __________

Reason for leaving ________________________________________________________________________________

Were you subject to the FMCSRs ** while employed? □ Yes □ No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Par 40? □ Yes □ No Explain any gaps in employment

_______________________________________________________________________________________________

Company: ________________________________________ Supervisor’s Name: ______________________________

Address: _____________________________________________________________ Phone: ( ) _______________

Position Held : ________________________________________From: _________ To: _________ Salary: __________

Reason for leaving ________________________________________________________________________________

Were you subject to the FMCSRs ** while employed? □ Yes □ No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Par 40? □ Yes □ No Explain any gaps in employment

_______________________________________________________________________________________________

Company: ________________________________________ Supervisor’s Name: ______________________________

Address: _____________________________________________________________ Phone: ( ) _______________

Position Held : ________________________________________From: _________ To: _________ Salary: __________

Reason for leaving ________________________________________________________________________________

Were you subject to the FMCSRs ** while employed? □ Yes □ No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Par 40? □ Yes □ No Explain any gaps in employment

_______________________________________________________________________________________________

Company: ________________________________________ Supervisor’s Name: ______________________________

Address: _____________________________________________________________ Phone: ( ) _______________

Position Held : ________________________________________From: _________ To: _________ Salary: __________

Reason for leaving ________________________________________________________________________________

Were you subject to the FMCSRs ** while employed? □ Yes □ No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Par 40? □ Yes □ No Explain any gaps in employment

_______________________________________________________________________________________________

Educational Background

A. List last three (3) schools attended, starting with last one. B. List number of years completed. C. Indicate degree or diploma earned, if any D. Grade Point Average or Class Rank and E. Major and minor field of study (if applicable).

|A. School |B. No. Years Completed |C. Degree Diploma |D. GPA Class Rank |E. Major |E. Minor |

| | | | | | |

| | | | | | |

| | | | | | |

References

List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

|Name |Telephone |Years Known |

| |( ) | |

| |( ) | |

| |( ) | |

Skills and Qualifications - summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work with our company. List any foreign language(s) you know

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

List professional, trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status.)

|Organization |Offices Held |

| | |

| | |

| | |

List special accomplishments, publications, awards (Exclude information which would reveal sex, race, religion, national origin, age, color, disability or other protected status) _____________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Have you ever served in the U.S. Military or Coast Guard?

If yes, list brand and dates of service:

________________________________________________________________________________________________

________________________________________________________________________________________________

EXPERIENCES AND QUALIFICATION

Attach separate sheet if more space is needed

Driving Experience

If no driving experience within the last 3 years – check here □

CLASS OF EQUIPMENT TYPE OF EQUIPMENT DATES APPROXIMATE

(Circle all that apply) FROM TO NUMBER OF MILES

Straight Truck Van, Reefer, Tank, Flat ______ ______ _________________

Tractor & Semi-Trailer Van, Reefer, Tank, Flat ______ ______ _________________

Tractor- Two Trailers Van, Reefer, Tank, Flat ______ ______ _________________

Tractor – Three Trailers Van, Reefer, Tank, Flat ______ ______ OR _________________

(Greater than

Motor coach- School Bus 8 passengers) N/A ______ ______ _________________

(Greater Than

Motor coach- School Bus 15 passengers) N/A ______ ______ _________________

Other: _______________________ Van, Reefer, Tank, Flat ______ ______ _________________

Accident History ( 3 years)

If no accidents within the last 3 years – check here □

DATE NATURE OF ACCIDENT NUMBER OF NUMBER OF CHEMICAL

(Month/year) (Head-on, rear-end, upset, etc.) FATALITIES INJURIES SPILLS?

__________ _________________________________ __________________ __________________ □ YES □ NO

__________ _________________________________ __________________ __________________ □ YES □ NO

__________ _________________________________ __________________ __________________ □ YES □ NO

Traffic Convictions and Forfeitures ( 3 years)

If no traffic convictions and/or forfeitures in the last 3 years- check here □

DATE CONVICTED VIOLATION STATE OF VIOLATION PENALTY

(month/year) (other than violations involving parking only) (forfeited bond, collateral and/or points)

_________________ ________________________ _______________________ ________________________

_________________ ________________________ _______________________ ________________________

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.

_________________________ ________________________________ _______________________

State License Number Expiration Date

A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? □ YES □ NO

If yes, give details____________________________________________________________________________

B. Has any license, permit, or privilege ever been suspended or revoked? □ YES □ NO

If yes, give details_____________________________________________________________________________

Applicant Certification

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 Signature Date

APPLICANT

RELEASE OF CONFIDENTIALITY

I, _________________________________________, hereby authorize my former employer(s), or its (their) agents, and any other person or entity shown on my “Application for Employment” with ________________________________ to respond fully, truthfully, and candidly to all inquiries regarding:

[ ] Dates of employment

[ ] Position(s) held

[ ] Pay and benefits

[ ] Safety record

[ ] Performance and ability

[ ] Discipline and attendance records

[ ] Reason for termination

[ ] Re-hire status

[ ] Other, listed below ______________________________________________________________________

[ ] DO NOT release information about the following: ____________________________

______________________________________________________________________

I understand that, without having signed and provided this release, companies and individuals may be reluctant to provide information regarding these matters other than dates of employment and position held, and I consider it to my advantage that they release more detailed information. By this authorization, I hold them harmless for the release of information that is accurate and truthful.

___________________________________________________________________ _________________________

Employee’s signature Date

___________________________________________________________________ _________________________

Witness signature Date

I UNDERSTAND THAT A DRUG TEST WILL BE ADMINISTERED PRIOR TO EMPLOYMENT WITH THIS COMPANY. I FURTHER UNDERSTAND AND AGREE THAT AT SUCH TIMES DURING MY EMPLOYMENT, AS THE COMPANY SHALL REQUIRE, I WILL PROVIDE URINE, BREATH OR BLOOD SPECIMENS TO BE TESTED FOR THE PRESENCE OF DRUGS OR ALCOHOL.

IF MY PRE-EMPLOYMENT DRUG TEST RESULTS PROVE “POSITIVE”, I UNDERSTAND THAT I AM OBLIGATED TO PAY FOR THE TESTING.

IF MY DRUG TEST RESULTS PROVE “NEGATIVE” AND I AM HIRED, THE COMPANY WILL PAY FOR MY TESTING FEE.

I HAVE READ, OR HAD READ TO ME, AND UNDERSTAND THE ABOVE STATEMENT AND CONSENT TO BEING DRUG TESTED.

SIGNATURE __________________________________________________________ DATE ___________________

WITNESS _____________________________________________________________

TO BE ELIGIBLE OR PERMITTED TO OPERATE A COMPANY VEHICLE YOU MUST BE QUALIFIED UNDER INSURABILITY CRITERIA. A REPORT OF YOUR DRIVING RECORD WILL BE REQUESTED FROM YOUR DRIVERS LICENSE ISSUING STATE’S DEPARTMENT OF TRANSPORTATION.

A DRIVER DISQUALIFIED FOR ANY REASON BECOMES INELIGIBLE FOR INSURANCE COVERAGE REQUIRED BY COMPANY POLICY AND IS DISQUALIFIED FOR ANY POSITIONS THAT REQUIRED DRIVING COMPANY VEHICLES.

I HAVE READ, OR HAD READ TO ME, AND UNDERSTAND THE ABOCE STATEMENT AND CONSENT TO HAVING MY DRIVING RECORDS RECEIVED.

SIGNATURE __________________________________________________________ DATE ___________________

WITNESS _____________________________________________________________

Please Read Paragraph Below (if there is any part of this page you do not understand, please ask the interviewer about it before signing).

I hereby authorize Edko, LLC to thoroughly investigate my references, work records, education and other matters related to my suitability for employment and , further, authorize my current and former employers to disclose to the company any and all letters, reports and other information pertaining to my employment with them, without giving me prior notice of such disclosure. In addition, I hereby release Edko, LLC my current and former employers, and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that if offered employment, the offer may be contingent on my passing a pre-employment alcohol and drug screen and pre-employment physical. By signing this application, I voluntarily agree to submit to a pre-employment alcohol/drug screen and pre-employment physical upon request. I understand that failure to pass the alcohol/drug screen and/or physical will result in withdrawal of the employment offer.

If hired, I also agree to submit to alcohol or drug testing as a condition of employment. I agree that Edko, LLC may conduct alcohol or drug screening at its sole discretion with or without notice. I also understand that refusal to submit to an alcohol/drug screen will be considered a voluntary resignation of employment.

I understand that nothing contained in the application or conveyed to me during any interview, which may be granted, is intended to create an employment contract, implied or explicit, between Edko, LLC and me. In addition, I understand and agree that if I am employed; my employment relationship with Edko, LLC is strictly voluntary and at our mutual will. I understand that if employed, my employment is for no definite period and may be terminated at any time, with or without prior notice, with or without cause or reason, at the option of either myself or Edko, LLC and that no promises or representation contrary to the forgoing are binding on the company unless made in writing and signed jointly by the President/CEO and myself.

I understand and agree that any future changes in my title, duties, compensation, working conditions, and/or Edko, LLC benefits; policies and procedures will not alter our at-will agreement.

I understand that if offered employment, I will as condition of employment, be required to submit proof of my identity and legal right to work in the United States on my first day of employment.

If the position applied for requires driving in the course of work, I understand that I will be required to possess a current and valid state driver’s license and understand that I will be required to provide a copy of my official driving record and proof of insurance. I also understand that any offer of employment is contingent on my ability to be covered by Edko, LLC auto insurance, if required for my position.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement on this application or on any documents used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

My signature below certifies that I have read and understand this complete page, and agree to the terms and conditions outlined in this document.

______________________________________________________ _______________________________

Applicant’s Signature Date

_______________________________________________________ _______________________________

Witness/Company Date

For Personnel Department Use Only

Position(s) applied for ………………………………………………………………………………… □ Available □ Not Available

Other positions considered for _______________________________________________________________________

_______________________________________________________________________________________________

Hired ………………………………………….. □ Yes □ No Date of Hire __________/_____/_____

Position hired for __________________________________________________________________________________

Job classification (circle one)

District Manager Contract Forester Laborers

Sales Contract Planner Safety

Office and Clerical Operator

Completed By _________________________________________________________________ Date _____/____/____

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