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Employee Application - Driver

Robert V. Jensen, Inc.

Employment Application (Please Print)

Name:

Last

First

Middle

Date of Application:

Address:

City:

State:

Zip:

Home Phone: ( )

Alternate Phone: ( )

Personal Information

Position applying for:

Type of work applying for:

Full-Time Part-Time Temporary

Days and hours you are available for work:

How did you hear about Robert V. Jensen, Inc. and this job opening:

Have you ever applied to or worked for Robert V. Jensen, Inc. before?

NoYes

If yes, state dates and position:

Are you at least 18 years old? (If under 18, hire is subject to minimum legal age verification)

YesNo

If hired, would you have a reliable means of transportation to and from work?

YesNo

Are you able to perform the essential functions of the job for which you are applying,
either with or without reasonable accommodation(s)?

YesNo

If no, please describe the functions that cannot be performed:

(Note: Robert V. Jensen, Inc. complies with the ADA and considers reasonable accommodation(s) that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

Robert V. Jensen, Inc. may refuse to hire relatives of present employees if doing so could result in actual or potential problems in supervision, security, safety, or morale, or if doing so could create conflicts of interest.

Education, Training and Experien

School Name & Address	Degree/Diploma	Did you graduate?	No. of Years Completed
		YesNo
		YesNo
		YesNo
		YesNo

Do you have any licenses, certifications, or other experience, training, qualifications or skills that you feel make you

especially suited for this position? If so, please explain:

Employment History

List below all present and past employment starting with your most recent employer (last 5 years is sufficient). You must complete this section even if attaching a resume.

Name of Employer:

Supervisor Name:

Address:

Telephone Number:

Dates of Employment (Month/Year):

Position & Duties:

Reason for Leaving:

May we Contact Employer: YesNo

Name of Employer:

Supervisor Name:

Address:

Telephone Number:

Dates of Employment (Month/Year):

Position & Duties:

Reason for Leaving:

May we Contact Employer: YesNo

Name of Employer:

Supervisor Name:

Address:

Telephone Number:

Dates of Employment (Month/Year):

Position & Duties:

Reason for Leaving:

May we Contact Employer: YesNo

References

List below three persons not related to you who have knowledge of your work performance within the last 3 years.

Name:

Occupation:

Address:

Phone Number:

No. of Years Acquainted:

Name:

Occupation:

Address:

Phone Number:

No. of Years Acquainted:

Name:

Occupation:

Address:

Phone Number:

No. of Years Acquainted:

Applicant Statement

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 of material fact on this application or on any document 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.

I hereby authorize Robert V. Jensen, Inc. to thoroughly investigate my references, employment history, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I further, authorize the references I have listed to disclose to the Company any and all letters, reports and other information related to my work records, except for salary history, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my 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 in compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

I understand that Robert V. Jensen, Inc. does not unlawfully discriminate in employment and no questions on this application are used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is at-will, meaning it is for no definite or determinable period and may be terminated at any time, with or without notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company’s President.

DO NOT SIGN UNLESS YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

Please be advised that Robert V. Jensen, Inc. will consider qualified applicants, including those with criminal histories, in a manner consistent with state and local “Fair Chance” laws.

I have read, fully understand and accept all terms of the above Applicant Statement.

Signature of Applicant:

Date:

Robert V. Jensen, Inc. is an Equal Opportunity Employer and a Drug-Free Workplace.

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

DATE	LOCATION	CHARGE	PENALTY

ACCIDENT RECORD FOR THE PAST 3 YEARS OR MORE SHEET IF MORE SPACE IS NEEDED)

DATE	NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)	INJURIES	FATALITIES

EMPLOYMENT RECORD

NOTE: DOT REQUIRES THAT EMPLOYMENT FOR AT LEAST 3 YEARS ANP/_QR COMMERCIAL DRIVING EXPERIENCE FOR THE PAST 10 YEARS BE SHOWN

CURRENT OR PREVIOUS EMPLOYERS:

1.	NAME TEL: ( ) ADDRESS SUPV: FROM TO SALARY: POSITION HELD: REASON FOR LEAVING:

2.	NAME TEL: ( ) ADDRESS SUPV: FROM TO SALARY: POSITION HELD: REASON FOR LEAVING:

3.	NAME TEL: ( ) ADDRESS SUPV: FROM TO SALARY: POSITION HELD: REASON FOR LEAVING:

**TO BE READ AND SIGNED BY APPLICANT**

THIS CERIFIES 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.

DATE

APPLICANT'S SIGNATURE

NOTE: A MOTOR CARRIER MAY REQUIRE AN APPLICANT TO PROVIDE INFORMATION IN ADDITION TO THE INFORMATION BY THE FEDERAL MOTOR CARRIERS SAFETY REGULATIONS. TLC

Transportation Management/Safety consultants, inc. 4709 N. EL CAPITAN, SUITE 207, FRESNO CA 93722 559-276-6207

Additional Employment History

List below all present and past employment starting with your most recent employer. Account for all periods of unemployment. You must complete this section even if attaching a resume.

Name Of Employer

Address: (NO.)

(Street)

(City)

(State)

(Zip)

Types of business:

Telephone No.
( )

Your Supervisor's Name

Your position and Duties

Date of Employment:form

Weekly pay:starting

Ending

Reason for Leaving:

Name Of Employer

Address: (NO.)

(Street)

(City)

(State)

(Zip)

Types of business:

Telephone No.
( )

Your Supervisor's Name

Your position and Duties

Date of Employment:form

Weekly pay:starting

Ending

Reason for Leaving:

Please Read Carefully, Initial Each paragraph and Sign Below

I hereby certify that I have not knowingly withheld any information that might adversely affect my 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 cmnpleted this application. I that any omission or misstatement of material fact on this application or on any document used to secure employment Shall be for rejection Of this application or for immediate discharge if am employed, regardless of the time elapsed before discovery.

l hereby authorize the Company to thoroughly investigate my references, work record, education, and other matters related to my suitability for employment and, Further, authorize the references I have listed to disclose to the company any and all letters, reports, and Other information related to my work records, Without giving me prior notice Of such disclosure, In addition, I hereby the company, my former employers and all other 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 hereby agree to submit to binding arbitration all disputes and claims arising out Of the submission of this application. I further agree, in the event that am hired by the company, that disputes that Cannot be resolved by informal internal resolution which might arise out of my employment with the company, whether during or after that employment, will be submitted to binding arbitration. I agree that such arbitration Shall be conducted under the rules of the American Arbitration Association. This application contains entire agreement between the parties with regard to dispute resolution, and there are no other agreements as to dispute resolution. either oral or written.

l understand that nothing contained in the application, or conveyed during any interview which may be granted or my employment, if hired, is intended to create an employment contract between me and the company, In addition, I understand and agree that if I am —employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contract to the foregoing are binding on the company unless made in writing signed by me and the company's designated representative.

Date

Applicant's Signature

Company:

Reviewed By:

Address:

Title:

City,State,Zip:

Date:

***PLEASE PRINT LEGIBLY*** READ CAREFULLY AND COMPLETE EACH QUESTION FULLY***

Name:(Last)

(First)

(Middle)

Business Telephone:
( )

Home Telephone:
( )

Cell Telephone:
( )

Present Address:

(City)

(State)

(Zip)

PREVIOUS ADDRESS IF CURRENT ADDRESS IS LESS THAN 3 YEARS:

Address:

(City)

(State)

(Zip)

HOW LONG?

Address:

(City)

(State)

(Zip)

HOW LONG?

(ATTACH SHEET IF MORE SPACE IS NEEDED)

DATE OF BIRTH:

SOCIAL SECURITY NO:

EXPERIENCE AND QUALIFICATIONS-DRIVER

DRIVER LICENSES HELD	LICENSE NO.	TYPE	STATE	EXPIRATION DATE

DRIVING EXPERIENCE

CLASS OF EQUIPMENT

TYPE OF EQUIPMENT
(VAN, TANK. FLAT, ETC.)

DATES
FROM	TO

APPROX. NO. OF
MILES (TOTAL)

STRAIGHT TRUCK

DATES

TRACTOR & SEMI-TRAILER

DATES

TRACTOR-TWO TRAILERS

DATES

OTHER

DATES

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

YES

B. Has any license, permit, or privilege ever been suspended or revoke?

YES

IF THE ANSWER TO EITHER "A" OR "B' YES. ATTACH STATEMENT GIVING DETAILS

MOTOR CARRIER NAME:

PREVIOUS PRE-EMPLOYMENT
ALCOHOL & CONTROLLED SUBSTANCES TESTING

****BE COMPLETED BY PROSPECTIVE EMPLOYEE****

THE FOLLOWING REQUESTED INFORMATION IS REQUIRED BY FEDERAL MOTOR CARRIER SAFETY REGULATION TITLE 49, PART 40, SECTION 40.25 (J)

PLEASE READ THE FOLLOWING INFORMATION VERY CAREFULLY AND ANSWER THE QUESTIONS TO THE BEST OF YOUR KNOWLEDGE. FAILURE TO COMPLETE THIS QUESTIONNAIRE PRECLUDES ANY CHANCE OF EMPLOYMENT WITH THIS COMPANY.

RELATIVE TO PRE-EMPLOYMENT SUBSTANCE ABUSE AND ALCOHOL MISUSE TESTING, AS A POTENTIAL EMPLOYEE APPLYING FORA POSITION AS A COMMERCIAL MOTOR VEHICLE OPERATOR WITH ANY MOTOR CARRIER EMPLOYER, IN THE PAST TWO YEARS HAVE YOU:

• TESTED POSITIVE FOR SUBSTANCE ABUSE?………………………………………

YES

• REFUSED A SUBSTANCE ABUSE TEST?………………..…………………..…....……

YES

• TESTED POSITIVE FOR AN ALCOHOL MISUSE TEST?…………………….……

YES

• REFUSED AN ALCOHOL MISUSE TEST?…..……...………………….………………

YES

IF YOU HAVE ANSWERED "YES" TO ANY ONE OF THE ABOVE QUESTIONS YOU MUST PROVIDE THE FOLLOWING INFORMATION (Section 382.605, Tide 49, CFR):

• YOUR SUBSTANCE ABUSE PROFESSIONAL'S (SAP):

NAME:

ADDRESS:

Telephone NUMBER:
( )

• COPY OF YOUR SAP PROGRAM CERTIFYING COMPLETION OF ALL REQUIREMENTS OR

• COPY OF YOUR SAP PROGRAM AND

• COPY OF YOUR RETURN-TO-DUTY NEGATIVE TEST RESULT AND

•COPY OF ALL YOUR FOLLOW-UP TESTS ADMINISTERED IN COMPLIANCE WITH YOUR SAP PROGRAM.

I CERTIFY THAT THE ABOVE INFORMATION PROVIDED BY ME IS TRUE AND CORRECT.

(PRINT NAME)

(SIGN)

(SOC.#)

(DATE)

REQUEST/CONSENT FOR INFORMATION FROM PREVIOUS EMPLOYER

THE INFORMATION REQUESTED IS REQUIRED BY FEDERAL MOTOR CARRIER
SAFETY REGULATIONS, TITLE 49, SECTIONS 40.25 AND 391.23

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

TO:

ADDRESS:

CITY,STATE,ZIP:

DATE:

RE:

SS#:

PERIOD OF EMPLOYMENT:

POSITION HELD:

I HEREBY AUTHORIZED YOU TO RELEASE/VERIFY ALL INFORMATION REGARDING MY IDENTIFICATION, EMPLOYMENT HISTORY, CHARACTER, CONDUCT, ALCOHOL AND CONTROLLED SUBSTANCES TESTING, MD ACCIDENT RECORD FOR THE PAST 3 YEARS TO:

PROSPECTIVE EMPLOYER:

ATTENTION:

TELEPHONE:

STREET:

FAX NO.:

CITY, STATE, ZIP:

APPLICANT'S SIGNATURE

DATE

SECTION 2: PREVIOUS EMPLOYER TO COMPLETE AS IT PERTAINS TO FMSCR SECTION 40.25

IF DRIVER WAS NOT SUBJECT TO PAST 382 TESTING REQUIREMENTS WHILE EMPLOYED BY THIS EMPLOYER, PLEASE CHECK HERE a AND SKIP TO SECTION 391.23 (OVER).

1.Has this person tested positive for a controlled substance in the past three years’?...........................

YES

2.Has this person refused a controlled substance test in the past three years?………………………..…….....

YES

3. Has this person had an alcohol test with a Breath Alcohol Concentration of 0.04
or greater in the past three years?……………………………………………………………………………………...…...…………

YES

4. Has this person refused a required alcohol test in the past three years?……………………...……………….

YES

5. Has this person violated any other DOT drug and alcohol regulation?……………...………………...………..

YES

If YES to any of the above questions, please give Substance Abuse Professional's name, address and phone number for further reference:

Name:

Telephone:

Address:

City, State,Zip:

THIS SECTION COMPLETED BY:

TITLE:

TLC TRANSPORTATION MANAGEMENT/SAFETY CONSULTANTS, INC PRONE (559) 276.6207 FAX: (559) 276-6206 (OVER)

(CONTINUED)

SECTION 3: PREVIOUS EMPLOYER TO COMPLETE AS IT PERTAINS TO FMCSR SECTION 391.23

APPLICANTS ACCIDENT RECORD FOR THE PREVIOUS 3 YEARS

DATE OF ACCIDENT	LOCATION CITY/STATE	NUMBER OF INJURIES	NUMBER OF FATALITIES	HAZARDOUS MATERIALS RELEASE (OTHER THAN FUEL RON FUEL TANES)
				YES NO
				YES NO
				YES NO

SECTION 4: APPLICANT'S PERFORMANCE HISTORY

	EXCELLENT	GOOD	FAIR	POOR
QUALITY OF WORK
CO-OPERATION WITH OTHERS
SAFETY HABITS
DRIVING SKILLS
ATTENDANCE RECORD

Why did applicant leave?

Would you re-hire?

Did applicant have custody of money or valuables?

Was Driver's license ever suspended or revoked?

COMMENTS:

COMPLETED BY:

TITLE:

SECTION 4: APPLICANT'S PERFORMANCE HISTORY

THIS FORM WAS

MAILED
FAXED

DATE:

COMPLETE BELOW WHEN INFORMATION IS OBTAINED:

DATE:

MAIL
FAX
PHONE
INTERVIEW

RECEIVED BY:

FILE CLOSED:

COMMENTS:

TLC TRANSPORTATION MANAGEMENT/SAFETY CONSULTANTS, INC PRONE (559) 276.6207 FAX: (559) 276-6206

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Timestamp

Audit

July 29, 2019 9:19 am PDT

Employee Application - Driver Uploaded by RV Jensen Admin - credit@rvjensen.com IP 206.169.107.66

July 30, 2019 1:31 pm PDT

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