Driver's Application for Employment Wylie Wilson Trucking, Inc. 27319 Highway 61 Red Wing, MN 55066 In compliance with Federal and State equal employment opportunity 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. * required fields for commercial drivers. Position(s) Applied for: Personal Information First Name:* Middle Name: Last Name:* Address: City: State: Zip: Duration Lived Here: Email:* Mobile Phone: Home Phone: Social Security Number: Date of Birth:* Can you provide proof of age? YesNo Available Start Date: All Previous Addresses of Residency During the Past Three Years Most Recent Previous Residence Address: City: State: Zip: Duration Lived Here: Second Most Recent Previous Residence Address: City: State: Zip: Duration Lived Here: Third Most Recent Previous Residence Address: City: State: Zip: Duration Lived Here: Employment Details Have you ever worked for this company before?: YesNo If "Yes" From: To: Position: Wage: Reason for Leaving: Are you employed now? YesNo If "No", when were you last employed? Referred By: Wage Sought: Are there any reasons why you might be unable to perform the functions of the job for which you have applied? YesNo If "yes", explain below if you wish to do so. Employment and Driving History All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding three years. For each, list complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional seven years of information on those employers for whom the applicant operated such vehicles.This includes vehicles having a GVWR of 26,001 pounds or more, vehicles designed to transport fifteen or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding. Most Recent Employer Employer: Address: City: State: Zip: Phone: Job Title: Supervisor's Name: Reason for Leaving: Start Date: End Date: Work Performed: Salary/Wage: May we check references? YesNo Second Most Recent Employer Employer: Address: City: State: Zip: Phone: Job Title: Supervisor's Name: Reason for Leaving: Start Date: End Date: Work Performed: Salary/Wage: May we check references? YesNo Third Most Recent Employer Employer: Address: City: State: Zip: Phone: Job Title: Supervisor's Name: Reason for Leaving: Start Date: End Date: Work Performed: Salary/Wage: May we check references? YesNo Fourth Most Recent Employer Employer: Address: City: State: Zip: Phone: Job Title: Supervisor's Name: Reason for Leaving: Start Date: End Date: Work Performed: Salary/Wage: May we check references? YesNo Fifth Most Recent Employer Employer: Address: City: State: Zip: Phone: Job Title: Supervisor's Name: Reason for Leaving: Start Date: End Date: Work Performed: Salary/Wage: May we check references? YesNo Accident Record List all of the accidents you have been in from the last three years. Most Recent Accident Date: Nature of Accident: (head-on, rear-end, upset, etc.) Number of Fatalities: Number of Injuries: Second Most Recent Accident Date: Nature of Accident: (head-on, rear-end, upset, etc.) Number of Fatalities: Number of Injuries: Third Most Recent Accident Date: Nature of Accident: (head-on, rear-end, upset, etc.) Number of Fatalities: Number of Injuries: Traffic Convictions List all traffic convictions or forfeitures from the past three years. Most Recent Traffic Conviction Location: Date: Charge: Penalty: Second Most Recent Traffic Conviction Location: Date: Charge: Penalty: Third Most Recent Traffic Conviction Location: Date: Charge: Penalty: Education & Experience High School Name: Address: City: State: Zip: Graduated?: YesNoIn Progress Degree: Business, Trade, or Technical School Name: Address: City: State: Zip: Graduated?: YesNoIn Progress Degree: College, Undergraduate Name: Address: City: State: Zip: Graduated?: YesNoIn Progress Degree: College, Graduate Name: Address: City: State: Zip: Graduated?: YesNoIn Progress Degree: Other Education Name: Address: City: State: Zip: Graduated?: YesNoIn Progress Degree: Driver Licences Driver Licence 1 State: License Number: Type: Expiration Date: Driver Licence 2 State: License Number: Type: Expiration Date: Driver Licence 3 State: License Number: Type: Expiration Date: Have you ever been denied a license, permit or privilege to operate a motor vehicle? YesNo Has any license, permit or privilege ever been suspended or revoked? YesNo If "Yes" answered for either of the above, please explain below. Driving Experience Straight Truck Type of Equipment: (van, tank, flat, etc.) Approximate Miles: From: To: Tractor & Semi-Trailer Type of Equipment: (van, tank, flat, etc.) Approximate Miles: From: To: Tractor & Two Trailers Type of Equipment: (van, tank, flat, etc.) Approximate Miles: From: To: Motor Coach & School Bus Type of Equipment: (van, tank, flat, etc.) Approximate Miles: From: To: Other Type of Equipment: (van, tank, flat, etc.) Approximate Miles: From: To: List states operated in during the last five years. List and describe special courses or training completed that will help you as a driver. What save driving awards do you hold and from whom? Please list any trucking, transportation or other experience that may help in your work for this company. List courses and training other than those shown elsewhere in this application. List any special equipment or technical materials you can work with (other than those already shown). Attachments If you have additional information no covered elsewhere, please save your information into a document and attach it here. 1. Attachments should be .DOC, .DOCX, .PDF, .RTF, or .TXT and not larger than 100k. 2. Make sure that your full name is in the file name -- e.g., "Work History - John Doe.doc". * Applicant's Statement This certifies 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. 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(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. I have read and understood the Applicant's Statement. * Fair Credit Reporting Act Disclosure Statement In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations. I have read and understood the Fair Credit Reporting Act Disclosure Statement.
