Hull Co-op Association - Driver Application

DRIVER’S APPLICATION FOR EMPLOYMENT

Hull Coop Association is an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, creed, color, age, sex, religion, national origin, marital status, physical or mental handicap, or arrest record. This application will remain effective for a period of thirty (30) days or until the position is filled.

Notice: Substance and Alcohol testing is required of the applicant driver.

I understand that the information in this application will be used and that prior employers will be contacted for purposes of investigation, as required by Sec. 391.23 of the Department of Transportation Regulations.

DRIVER’S APPLICATION FOR EMPLOYMENT

Notice: Substance and Alcohol testing is required of the applicant driver.

Personal Information

Date of Application:

Applicant Name:

Last Name:

First Name:

Middle Name:

Present Address:

Street:

City:

State:

Zip Code:

Dates:

From:

To:

Phone Number:

Date of Birth (Required for Truck Drivers):

Can you provide proof of age?

Yes

Are you currently employed now?

Yes

Email Address:

Addresses for the past three (3) years:

Previous Address:

Street:

City:

State:

Zip Code:

Dates:

From:

To:

Previous Address:

Street:

City:

State:

Zip Code:

Dates:

From:

To:

Email Address:

Are you legally eligible for employment in the United States?

Yes

Position Desired:

When will you be available to begin work?

Salary Desired:

Have you previously worked for this company?

Yes

If so, from:

To:

Position:

Rate of Pay:

Reason for leaving:

Former supervisor(s) at this company:

How did you learn of this opening?

Who referred you?

State the name of any relative, other than a spouse, already employed by this company:

Have you ever been convicted of a felony?*:

Yes

If yes, give details, including date(s):

*A â€œyesâ€ answer will not automatically disqualify you from employment. We will consider the nature and date of the offense and the job for which you are applying for job-related purposes only, and only to the extent permitted by applicable law.

Education

High School

Name:

Location

Did you Graduate?

Yes

Subjects, Studies, and Degree(s):

College

Name:

Location:

Subjects, Studies, and Degree(s):

Did you Graduate?

Yes

Trade, Business, or Correspondence School

Name:

Location:

Did you Graduate?

Yes

Subjects, Studies, and Degree(s):

Other education or training:

Other special skills:

Driving Experience

Class of Equipment:

Straight Truck

Tractor & Semi-Trailer

Twin Trailers

Material Handling Equipment

Other

If other, Please Specify:

Type of Equipment (Van, Tank, Flat, etc.):

Dates From/To:

List states operated in for last five (5) years:

List special courses or training that will help you as a driver:

Do you have any safe driving awards?

Yes

From whom?

List special equipment you can work with (other than those already shown):

Accident Record for the past three (3) years or more

Dates:

Nature of accident (Head-on, Rear-end, Roll-over, etc.):

Fatalities:

Injuries/Non Injury:

Traffic Convictions and Forfeitures for the past three (3) years (other than parking violations):

Dates:

Where:

Violations (charges):

Penalties:

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

Yes

If yes, where?

When?

Is your license to drive suspended or revoked at this time, in any state?

Yes

If yes, where?

When?

Has ANY license, permit or driving privilege EVER been suspended or revoked?

Yes

If yes, where?

When?

Is your driving privilege limited in any way, such as probation, area operation, limitations of hours, etc., at this time?

Yes

If yes, why?

Are you familiar with DOT Motor Carrier Safety Regulations?

Yes

Do you agree to follow them?

Yes

Employment Record

NOTE: DOT requires that employment for at least three (3) years and/or Commercial Driving Experience for the past 10 years be shown.

Last Employer:

Position Held:

Address:

Street:

City:

State:

Zip Code:

From:

To:

Duties:

Reason for Leaving:

Contact Person:

Phone Number:

May we contact?

Yes

Starting Salary:

Final Salary:

Did you operate a Commercial Motor Vehicle for this employer?

Yes

List type of Commercial Motor Vehicle or Equipment operated for this employer: (Tractor, Bobtail, Straight Truck, Applicator, Forklift, etc.):

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Employer:

Position Held:

Address:

Street:

City:

State:

Zip Code:

From:

To:

Duties:

Reason for Leaving:

Contact Person:

Phone Number:

May we contact?

Yes

Starting Salary:

Final Salary:

Did you operate a Commercial Motor Vehicle for this employer?

Yes

List type of Commercial Motor Vehicle or Equipment operated for this employer: (Tractor, Bobtail, Straight Truck, Applicator, Forklift, etc.):

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Employer:

Position Held:

Address:

Street:

City:

State:

Zip Code:

From:

To:

Duties:

Reason for Leaving:

Contact Person:

Phone Number:

May we contact?

Yes

Starting Salary:

Final Salary:

Did you operate a Commercial Motor Vehicle for this employer?

Yes

List type of Commercial Motor Vehicle or Equipment operated for this employer: (Tractor, Bobtail, Straight Truck, Applicator, Forklift, etc.):

DOT Drug & Alcohol Testing

Have you been employed in a position subject to DOT Regulations in the past three (3) years?

Yes

Have you ever tested positive on a DOT-approved drug and/or alcohol test?

Yes

Have you ever refused to test on a DOT-approved drug and/or alcohol test?

Yes

References

Give below the name of three persons not related to you, whom you have known for at least one year.

Name:

Phone Number:

How Acquainted:

Years Acquainted:

Name:

Phone Number:

How Acquainted:

Years Acquainted:

Name:

Phone Number:

How Acquainted:

Years Acquainted:

Applicant's Statement

I certify 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, I have not withheld any facts or circumstances. Hull Cooperative Association may investigate all statements contained in this application, and I understand that any false or misleading information provided may result in my immediate discharge if I am hired. Similarly, any false or misleading information provided in post-offer questionnaires or medical examinations will result in discharge regardless of when discovered. I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT ODF EMPLOYMENT. I ALSO UNDERSTAND THAT IF HIRED, REGARDLESS OF ANY ORAL REPRESENTATIONS TO THE CONTRARY, THE EMPLOYMENT RELATIONSHIP BETWEEN MYSELF AND THE COMPANY IS TERMINABLE-AT-WILL. BOTH HULL COOPERATIVE ASSOCIATION AND I REMAIN FREE TO CHOOSE TO END OUR WORK RELATIONSHIP AT ANY TIME FOR ANY OR NO REASON. ANY CHANGES IN THIS EMPLOYMENT RELATIONSHIP MUST BE MADE IN WRITING. I further agree that, if employed, I will conform my conduct to Hull Cooperative Associationâ€™s rules, regulations, and personnel policies.

I also understand that any offer of employment may be conditioned upon a health evaluation by a doctor selected by Hull Cooperative Association to determine whether I qualify for the position being considered. I authorize Hull Cooperative Association to make a thorough investigation of my past employment, education, and job-related activities, and I release from liability all persons, companies, and corporations supplying such information. I also indemnify Hull Cooperative Association against any liability that might result from making such an investigation.

Applicantâ€™s Signature

Date

Required field

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Driver Application

Personal Information

Applicant Name:

Present Address:

Dates:

Addresses for the past three (3) years:

Previous Address:

Dates:

Previous Address:

Dates:

*A â€œyesâ€ answer will not automatically disqualify you from employment. We will consider the nature and date of the offense and the job for which you are applying for job-related purposes only, and only to the extent permitted by applicable law.

Education

High School

College

Trade, Business, or Correspondence School

Driving Experience

Accident Record for the past three (3) years or more

Traffic Convictions and Forfeitures for the past three (3) years (other than parking violations):

Employment Record

NOTE: DOT requires that employment for at least three (3) years and/or Commercial Driving Experience for the past 10 years be shown.

Address:

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Address:

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Address:

DOT Drug & Alcohol Testing

References

Give below the name of three persons not related to you, whom you have known for at least one year.

Applicant's Statement

*A â€œyesâ€ answer will not automatically disqualify you from employment. We will consider the nature and date of the offense and the job for which you are applying for job-related purposes only, and only to the extent permitted by applicable law.