Job Application

Applicant Information
In compliance with Federal and State Equal Employment Opportunity (EEO) laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.
Full Name:
SS#:  (Ex:  999887777)
Phone: (Ex: 9045556789) Cellular Phone:      (Ex: 9045556789)
Date of Birth: (Ex: 08/23/1956) Email Address:   
List your addresses of residency for the past 3 years:
Address: City, State & Zip:   
             Months: 
Previous Address: City, State & Zip: 
             Months: 
Previous Address: City, State & Zip: 
             Months: 
Do you have a DWI or DUI on your Driver record at any time in the past?  Have you ever been convicted of a crime? 
If so, give date of DUI:    (Ex: 08/23/1956) If so, explain the crime:  (max length 145)
Have you ever tested positive on a DOT drug or alcohol test, pre-employment or otherwise?  Are you employed now? 
If so, give date of drug test:    (Ex: 08/23/1956) If so, may we inquire of present employer? 
Emergency Contact Information:
Name: Relationship: 
Phone: Workplace: 
Who referred you? 
Employment History
Please complete with your previous 10 years work history, starting with your most recent employer.  Cover all time for the last 10 years.  If you were unemployed for more than 30 days, indicate each of those time periods in one of the employer boxes.
Employer 1
Dates
Name:
From
To
Address: Month:  Month: 
City, State & Zip: Year:  Year: 
Contact Person: Position Held: 
Phone Number: Salary/Wage: 
Were you subject to the FMCSRs while employed:  Reason For Leaving: 
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 Part 40? 
Employer 2
Dates
Name:
From
To
Address: Month:  Month: 
City, State & Zip: Year:  Year: 
Contact Person: Position Held: 
Phone Number: Salary/Wage: 
Were you subject to the FMCSRs while employed:  Reason For Leaving: 
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 Part 40? 
Employer 3
Dates
Name:
From
To
Address: Month:  Month: 
City, State & Zip: Year:  Year: 
Contact Person: Position Held: 
Phone Number: Salary/Wage: 
Were you subject to the FMCSRs while employed:  Reason For Leaving: 
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 Part 40? 
Employer 4
Dates
Name:
From
To
Address: Month:  Month: 
City, State & Zip: Year:  Year: 
Contact Person: Position Held: 
Phone Number: Salary/Wage: 
Were you subject to the FMCSRs while employed:  Reason For Leaving: 
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 Part 40? 
Employer 5
Dates
Name:
From
To
Address: Month:  Month: 
City, State & Zip: Year:  Year: 
Contact Person: Position Held: 
Phone Number: Salary/Wage: 
Were you subject to the FMCSRs while employed:  Reason For Leaving: 
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 Part 40? 
Employer 6
Dates
Name:
From
To
Address: Month:  Month: 
City, State & Zip: Year:  Year: 
Contact Person: Position Held: 
Phone Number: Salary/Wage: 
Were you subject to the FMCSRs while employed:  Reason For Leaving: 
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 Part 40? 
Employer 7
Dates
Name:
From
To
Address: Month:  Month: 
City, State & Zip: Year:  Year: 
Contact Person: Position Held: 
Phone Number: Salary/Wage: 
Were you subject to the FMCSRs while employed:  Reason For Leaving: 
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 Part 40? 
Employer 8
Dates
Name:
From
To
Address: Month:  Month: 
City, State & Zip: Year:  Year: 
Contact Person: Position Held: 
Phone Number: Salary/Wage:    (numeric only)
Were you subject to the FMCSRs while employed:  Reason For Leaving: 
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 Part 40? 
Employer 9
Dates
Name:
From
To
Address: Month:  Month: 
City, State & Zip: Year:  Year: 
Contact Person: Position Held: 
Phone Number: Salary/Wage: 
Were you subject to the FMCSRs while employed:  Reason For Leaving: 
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 Part 40? 
Employer 10
Dates
Name:
From
To
Address: Month:  Month: 
City, State & Zip: Year:  Year: 
Contact Person: Position Held: 
Phone Number: Salary/Wage: 
Were you subject to the FMCSRs while employed:  Reason For Leaving: 
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 Part 40? 
Employer 11
Dates
Name:
From
To
Address: Month:  Month: 
City, State & Zip: Year:  Year: 
Contact Person: Position Held: 
Phone Number: Salary/Wage: 
Were you subject to the FMCSRs while employed:  Reason For Leaving: 
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 Part 40? 
Employer 12
Dates
Name:
From
To
Address: Month:  Month: 
City, State & Zip: Year:  Year: 
Contact Person: Position Held: 
Phone Number: Salary/Wage: 
Were you subject to the FMCSRs while employed:  Reason For Leaving: 
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 Part 40? 
Driver License Information
List the valid operating license in your possession:
CDL Class:      State:       Number:       Expiration Date:  (Ex:  07/24/1999)
Have you ever lost your driving privileges?                       Haz/Mat Endorsement: 
If so, explain why you lost your driving privileges:    (max length is 134)
Driving Violations
List below all moving violations you have received in the past five (5) years. Be as specific as possible:
Date (Ex: 08/23/1956) Offense Location Type of Vehicle
Traffic Accidents
Date (Ex: 08/23/1956) Nature of Accident Fatalities Personal Injury
Experience
Explain experience you have driving.  If you have operated motor vehicle equipment, explain the types and name of states driven in.
 (max length is 185)
Comments
Please list any comments or information you think we need for considering your application:
 (max length is 250)
Acknowledgment
This certifies this online 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 authorize you 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 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 may result in discharge.  I understand, also, that I am required to abide by all rules and regulations of Davis Express.
Date:    (Ex: 08/23/1956) Your Initials: 

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