Driver's Application | Asphalt Paving Contractor Daytona Beach, FL

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Equal Opportunity Employer & Drug-Free Workplace

"*" indicates required fields

Applicant Name:*

Date of Application:*

Email Address:*

Company:*

Address:*

Street City State ZIP Code

In compliance with Federal and State equal employment opportunity laws all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other protected status.

To Be Read and Signed by Applicant

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

Review information provided by previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

Signature:*

Date:*

Applicant to Complete

(answer all questions)

Position(s) Applied For:*

Name*

First Middle Last

Social Security No.:*

Preferred Name:

List your addresses of residency for the past 3 years.

Current Address:*

Street City State ZIP Code

How Long? (yr./mo.):*

Phone Number:*

Previous Addresses:

State

City

State & Zip Code

How Long (yr./mo.)

Do you have the legal authority to work in the United States?*

Yes

Date of Birth:*

(Required for Commercial Drivers)

Have you worked for this company before?*

Yes

Where?*

Date From:*

Date To:*

Position:*

Reason for Leaving:*

Who Referred You?*

Have you ever been bonded?

Yes

Name of Bonding Company:

Can you perform, with or without reasonable accommodation, the essential functions of the job (as described in the attached job description)?*

Yes

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. 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 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent.)

Employer:

Name:

Date Employed From:

Date Employed To:

Address:

Street City State ZIP Code

Position Held:

Reason for Leaving:

Contact Person:

Phone Number:

Were You Subject to the FMCSRs† While Employed?

Yes

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?

Yes

Add Additional Employers:

Enter a Second Employer?

Yes

Name:

Date Employed From:

Date Employed To:

Address:

Street City State ZIP Code

Position Held:

Reason for Leaving:

Contact Person:

Phone Number:

Were You Subject to the FMCSRs† While Employed?

Yes

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?

Yes

Enter a Third Employer?

Yes

Name:

Date Employed From:

Date Employed To:

Address:

Street City State ZIP Code

Position Held:

Reason for Leaving:

Contact Person:

Phone Number:

Were You Subject to the FMCSRs† While Employed?

Yes

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?

Yes

Enter a Fourth Employer?

Yes

Name:

Date Employed From:

Date Employed To:

Address:

Street City State ZIP Code

Position Held:

Reason for Leaving:

Contact Person:

Phone Number:

Were You Subject to the FMCSRs† While Employed?

Yes

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?

Yes

Enter a Fifth Employer?

Yes

Name:

Date Employed From:

Date Employed To:

Address:

Street City State ZIP Code

Position Held:

Reason for Leaving:

Contact Person:

Phone Number:

Were You Subject to the FMCSRs† While Employed?

Yes

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?

Yes

Enter a Sixth Employer?

Yes

Name:

Date Employed From:

Date Employed To:

Address:

Street City State ZIP Code

Position Held:

Reason for Leaving:

Contact Person:

Phone Number:

Were You Subject to the FMCSRs† While Employed?

Yes

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?

Yes

*Includes vehicles having a GVW or GVWR of 26,001 lbs. or more, a vehicle combination with a weight rating or actual weight of 26,001 pounds or more inclusive of a towed unit with a rated or actual weight of 10,001 pounds or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

^†The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers for compensation (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Accident Record

FOR PAST 3 YEARS OR MORE. IF NONE, WRITE NONE.

List Accidents:*

Dates

Nature of Accident*

Fatalities

Injuries

Haz-Mat Spill

*(Head-on, rear-end, upset, etc.)

Traffic Convictions

AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS). IF NONE, WRITE NONE.

List Convictions:*

Location

Date

Charge

Penalty

Experience and Qualifications - Driver

DRIVER LICENSES OR PERMITS IN THE PAST 3 YEARS

List Licenses:*

Issuer

License No.

Class

Endorsement(s)

Expiration Date

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 revoked?*

Yes

IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS:*

Driving Experience

CHECK YES OR NO

Class of Equipment

Straight Truck:*

Yes

Type of Equipment:*

Date From:*

Date To:*

Approx. No. of Miles:*

(Total)

Tractor and Semi-Trailer:*

Yes

Type of Equipment:*

Date From:*

Date To:*

Approx. No. of Miles:*

(Total)

Tractor - Two Trailers:*

Yes

Type of Equipment:*

Date From:*

Date To:*

Approx. No. of Miles:*

(Total)

Tractor - Three Trailers:*

Yes

Type of Equipment:*

Date From:*

Date To:*

Approx. No. of Miles:*

(Total)

Motorcoach - School Bus:*

Yes

More than 8 passengers

Date From:*

Date To:*

Approx. No. of Miles:*

(Total)

Motorcoach - School Bus:*

Yes

More than 15 passengers

Date From:*

Date To:*

Approx. No. of Miles:*

(Total)

Other

List States Operated in For Last Five Years:*

Show Special Courses or Training That Will Help You as a Driver:

Which Safe Driving Awards Do You Hold and From Whom?

Experience and Qualifications - Other

Show Any Trucking, Transportation or Other Experience That May Help in Your Work for This Company:

List Courses and Training Other Than Shown Elsewhere in This Application:

List Special Equipment or Technical Materials You Can Work With (Other Than Those Already Shown):

Education

Select Highest Grade Completed:

High School:

College:

Last School Attended:

(Name)

City, State:

Signature:*

Date:*

Motor Vehicle Release Consent Form

In conjunction with my employment, or volunteer work at/with P & S Paying, Inc. ("the company"), I

Applicant Name:*

(applicant) consent to the release of my Motor Vehicle Record (MVR) to the company. I understand the company will use these records to evaluate my suitability to fulfill driving duties that may be related to the position for which I am applying. I also consent to the review, evaluation, and other use of any MVR I may have provided to the company. This consent is given in satisfaction of Public law 18 USC 2721 er. Seq .. "Federal Drivers Privacy Protection Act," and is intended to constitute "written consent" as required by this Act.

Driver’s License Number:*

State:*

Date of Birth:*

Signature:*

Date:*

General Consent for Limited Queries of Federal Motor Carrier Safety Administration (FMCSA) Drug & Alcohol Clearinghouse (CDL Only)

I, Applicant Name:*

(applicant) hereby provide consent to P & S Paving, Inc. to conduct a limited query of the FM CSA Commercial Driver's License Drug & Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. This consent extends to pre-employment and annual review of the Clearinghouse.

I understand that if the limited query conducted by P & S Paving, Inc. indicates that drug or alcohol violation information about me in the Clearinghouse, FMCSA will not disclose the information to P & S Paving, Inc. without first obtaining specific consent from me.

I further understand that if I refuse to provide consent for P & 5 Paving, Inc. to conduct a limited query of the Clearinghouse, P & S Paving, Inc. must prohibit me from preforming safetysensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations.

Signature:*

Date:*

Acknowledgements & Disclosures

I give the company the right to contact and obtain information from all references, employers, and schools to verify the accuracy of the information contained in this application. I hereby release the company and its representatives from liability for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information.
This application is current for only 60 calendar days from the date received by company (as indicated above). At the conclusion of the 60-day period, if I have not heard from the company and still wish to be considered for employment, it will be necessary to fill out a new application.
I understand that if I am employed, any misrepresentation or material omission made by me on this application may be sufficient cause for immediate termination, whenever it is discovered.
I understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States verifiable by eVerify in the State of Florida, and that Federal immigration laws require me to complete an 1-9 form in this regard.
I understand it is this company's policy not to refuse to hire a qualified individual with a disability because of that person's need for a reasonable accommodation as required by ADA. The company does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state, or federal law.
This application does not constitute an agreement or contract for employment for any specific period or definite duration. I understand that no representative of the company, other than an authorized officer, has the authority to make any assurances to the contrary.
I understand that any offer of employment I may receive from company is contingent upon my successful completion of the company's total pre-employment screening process, including the company's receiving references that it considers satisfactory, and my satisfactory completion of any background investigation that the company may require.
I certify that the information contained in this application and any other information that I provide company is true and accurate.
In consideration of my employment, I agree to comply with the policies, rules, regulations and procedure of company.
I understand that nothing in this application, or conveyed during interview that may or may not be granted, or during my employment, if I am hired, is intended to create a contract for continued employment between company and me. In addition, I understand that if I am employed, my employment at company shall be at will.

Signature of Applicant:*

Date:*

Drug-Free Workplace Policy Acknowledgement

I have been told and understand that company has a policy whereby employees using or under the influence of alcohol or chemical substance during work hours may be immediately terminated.

I agree that under the appropriate circumstances, particularly if I am involved in an accident during working hours, I may be required and will submit to a test administered by a qualified authority that will determine if alcohol or chemical substances are present. I understand that a positive result of this test will affect my eligibility for workers’ compensation benefits.

I further understand that employment and continued employment depends upon my agreement to submit voluntarily to tests or the detection of the presence of alcohol or drugs. Refusing such a test will result in my immediate termination.

Signature of Applicant:*

Date:*

Equal Employment Opportunity

Applicants are considered for all positions, and employees are treated equally during employment without regard to race, color, religion, sex, national origin, age, or disability to include pregnancy, sexual orientation and gender identity.

As employers/government contractors, we comply with government regulations and affirmative action responsibilities. This data is for periodic government reporting (EEO-1). It is collected solely to help comply with government record keeping, reporting and other legal requirements.

Gender:*

Male

Female

Race / Ethnic Group:*

Black or African American

White (Not Hispanic or Latino)

Hispanic or Latino

Asian

American Indian or Alaskan Native

Decline to Answer

Two or More Races

Referral Source

Select Source(s):*

School

Employee

Walk-In

Relative / Friend

P & S Paving, Inc. Website

Previously Employed at P & S Paving, Inc.

If School, please explain:*

If Employee, please explain:*

This field is for validation purposes and should be left unchanged.

Driver’s Application

Fill Out the Digital Application Below or Download the PDF

Equal Opportunity Employer & Drug-Free Workplace

To Be Read and Signed by Applicant

Applicant to Complete

List your addresses of residency for the past 3 years.

Employment History

Employer:

Add Additional Employers:

Accident Record

Traffic Convictions

Experience and Qualifications - Driver

Driving Experience

Class of Equipment

Experience and Qualifications - Other

Education

Motor Vehicle Release Consent Form

General Consent for Limited Queries of Federal Motor Carrier Safety Administration (FMCSA) Drug & Alcohol Clearinghouse (CDL Only)

Acknowledgements & Disclosures

Drug-Free Workplace Policy Acknowledgement

Equal Employment Opportunity

Referral Source

Quick Links

Office Hours

Contact