Robert V. Jensen, Inc.
Employment Application (Please Print)
Address:
Personal Information
Position applying for:
Days and hours you are available for work:
Days and hours you are available for work:
How did you hear about Robert V. Jensen, Inc. and this job opening:
If yes, state dates and position:
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation(s)?
(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
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.
References
List below three persons not related to you who have knowledge of your work performance within the last 3 years.
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.
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)
ACCIDENT RECORD FOR THE PAST 3 YEARS OR MORE SHEET IF MORE SPACE IS NEEDED)
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:
**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.
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
Types of business:
Your position and Duties
Reason for Leaving:
Name Of Employer
Types of business:
Your position and Duties
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.
***PLEASE PRINT LEGIBLY*** READ CAREFULLY AND COMPLETE EACH QUESTION FULLY***
PREVIOUS ADDRESS IF CURRENT ADDRESS IS LESS THAN 3 YEARS:
(ATTACH SHEET IF MORE SPACE IS NEEDED)
EXPERIENCE AND QUALIFICATIONS-DRIVER
DRIVING EXPERIENCE
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
B. Has any license, permit, or privilege ever been suspended or revoke?
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?………………………………………
• REFUSED A SUBSTANCE ABUSE TEST?………………..…………………..…....……
• TESTED POSITIVE FOR AN ALCOHOL MISUSE TEST?…………………….……
• REFUSED AN ALCOHOL MISUSE TEST?…..……...………………….………………
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):
• 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.
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
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:
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’?...........................
2. Has this person refused a controlled substance test in the past three years?………………………..…….....
3. Has this person had an alcohol test with a Breath Alcohol Concentration of 0.04 or greater in the past three years?……………………………………………………………………………………...…...…………
4. Has this person refused a required alcohol test in the past three years?……………………...……………….
5. Has this person violated any other DOT drug and alcohol regulation?……………...………………...………..
If YES to any of the above questions, please give Substance Abuse Professional's name, address and phone number for further reference:
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
SECTION 4: APPLICANT'S PERFORMANCE HISTORY
SECTION 4: APPLICANT'S PERFORMANCE HISTORY
COMPLETE BELOW WHEN INFORMATION IS OBTAINED:
TLC TRANSPORTATION MANAGEMENT/SAFETY CONSULTANTS, INC PRONE (559) 276.6207 FAX: (559) 276-6206