Online Application - SR&R Environmental

General Information
Date of Application*
MM slash DD slash YYYY
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
- No
Do you have a pending charge or past conviction for driving while intoxicated?*
- Yes
- No
Do you have a pending charge or past conviction for possession of a controlled substance?*
- Yes
- No
Have you ever been refused auto liability insurance?*
- Yes
- No
Do you have a pending charge or past conviction for any misdemeanor or felony offense?*
- Yes
- No
Employment History
List employment for the last 10 years.
Last Employer
Name
Address
Phone
Was this position under FMCSA regulations?
- Yes
- No
Were you in an ACTIVE drug and alcohol testing program?
- Yes
- No
Position Held
Dates Held
Salary
Reason for Leaving
Second Employer
Name
Address
Phone
Was this position under FMCSA regulations?
- Yes
- No
Were you in an ACTIVE drug and alcohol testing program?
- Yes
- No
Position Held
Dates Held
Salary
Reason for Leaving
Third Employer
Name
Address
Phone
Was this position under FMCSA regulations?
- Yes
- No
Were you in an ACTIVE drug and alcohol testing program?
- Yes
- No
Position Held
Dates Held
Salary
Reason for Leaving
Fourth Employer
Name
Address
Phone
Was this position under FMCSA regulations?
- Yes
- No
Were you in an ACTIVE drug and alcohol testing program?
- Yes
- No
Position Held
Dates Held
Salary
Reason for Leaving
Fifth Employer
Name
Address
Phone
Was this position under FMCSA regulations?
- Yes
- No
Were you in an ACTIVE drug and alcohol testing program?
- Yes
- No
Position Held
Date Held
Salary
Reason for Leaving
Employment
Job applied for*
Salary desired
Have you applied here before?
- Yes
- No
When did you apply?
Have you ever worked for this company before?
- Yes
- No
When did you work here?
If you worked under a different name, what was it?
Are you available to work any shift?
- Yes
- No
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
- No
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.

State	Driver's License #	Type	Expiration Date

Dates	Nature of Accident	Fatalities	Injuries

Equipment Class	Equipment Type	Dates Driven	Approx # of Miles

Location	Date	Charge	Penalty

General Information

Driver's License Information

Accident Record

Driving Experience

Traffic Convictions & Forfeitures

Employment History

Last Employer

Second Employer

Third Employer

Fourth Employer

Fifth Employer

Employment

Educational Data

Relatives In Our Employment

Military

Special Skills

References

Application Addendum

Rights

Applicant's Certification and Agreement