Online Application - SR&R Environmental

General Information

Date of Application*

Name*

Phone Number*

Address*

Driver's License Information

State

Driver's License #

Type

Expiration Date

Accident Record

List your accident record for the past 3 years.

Dates

Nature of Accident

Fatalities

Injuries

Driving Experience

Equipment Class

Equipment Type

Dates Driven

Approx # of Miles

Traffic Convictions & Forfeitures

For the past 3 years, do not include parking violations.

Location

Date

Charge

Penalty

Have you ever had any type of motor vehicle license suspended or revoked, or ever been denied a license, permit of privilege to operate a motor vehicle?*

Yes

Do you have a pending charge or past conviction for driving while intoxicated?*

Yes

Do you have a pending charge or past conviction for possession of a controlled substance?*

Yes

Have you ever been refused auto liability insurance?*

Yes

Do you have a pending charge or past conviction for any misdemeanor or felony offense?*

Yes

Employment History

List employment for the last 10 years.

Last Employer

Name

Address

Phone

Was this position under FMCSA regulations?

Yes

Were you in an ACTIVE drug and alcohol testing program?

Yes

Position Held

Dates Held

Salary

Reason for Leaving

Second Employer

Name

Address

Phone

Was this position under FMCSA regulations?

Yes

Were you in an ACTIVE drug and alcohol testing program?

Yes

Position Held

Dates Held

Salary

Reason for Leaving

Third Employer

Name

Address

Phone

Was this position under FMCSA regulations?

Yes

Were you in an ACTIVE drug and alcohol testing program?

Yes

Position Held

Dates Held

Salary

Reason for Leaving

Fourth Employer

Name

Address

Phone

Was this position under FMCSA regulations?

Yes

Were you in an ACTIVE drug and alcohol testing program?

Yes

Position Held

Dates Held

Salary

Reason for Leaving

Fifth Employer

Name

Address

Phone

Was this position under FMCSA regulations?

Yes

Were you in an ACTIVE drug and alcohol testing program?

Yes

Position Held

Date Held

Salary

Reason for Leaving

Employment

Job applied for*

Salary desired

Have you applied here before?

Yes

When did you apply?

Have you ever worked for this company before?

Yes

When did you work here?

If you worked under a different name, what was it?

Are you available to work any shift?

Yes

Any day of the week?

What shifts and days are you available?

When could you report for work?

Educational Data

Highest Grade Completed

List Degrees Obtained

Relatives In Our Employment

Name

Relationship

Military

Branch of Service

Duties in Service

Special Skills

What knowledge, special technical or computer skills, and/or other qualifications have you acquired from employment or other experience? Include any specific equipment that you can proficiently operate.*

List any first aid or emergency response training for which you are currently certified (give date of certification).

References

Give 3 references who are not relatives or former employers.

Name

Occupation

Yrs Known

Phone

Address

Application Addendum

Federal Motor Carrier Safety Regulations §40.25 (j) The employer must ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years.

Have you ever tested positive, or refused to test, on any pre-employment drug test or have you tested .02 or greater, or refused to test, on any pre-employment alcohol test during the past two years?*

Yes

Rights

Pursuant to 49CFR, § 391.23 (j), you have the following rights regarding investigative information: 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 the prospective employer. 3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

Applicant's Certification and Agreement

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. I authorize you to make such investigations and inquire of my personal, employment, financial or medical history and other related manners 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 connections 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 AFFIRM THAT THE ABOVE STATEMENT IS TRUE

Name

This field is for validation purposes and should be left unchanged.