APPLICATION FOR EMPLOYMENT
COMPANY ___ EZRAF LLC dba Presidential Limousines ___ STREET ADDRESS___3271 HWY 100_____
CITY, STATE, ZIP CODE ___Villa Ridge MO 63089_________________________________________
NAME _______________________________________________________________________________
(FIRST) (MIDDLE) (MAIDEN NAME IF ANY) (LAST)
ADDRESS _____________________________________________________ HOW LONG? _____________
(STREET) (CITY) (STATE & ZIP CODE)
DATE OF BIRTH ____________ SOCIAL SECURITY NO. _______________________ HIRE DATE _________
TELEPHONE NUMBER _________________________ E-MAIL ADDRESS ___________________________
PREVIOUS THREE YEARS RESIDENCY
_______________________________________________________________________ # YEARS ______
(STREET) (CITY) (STATE & ZIP CODE)
_______________________________________________________________________ # YEARS ______
(STREET) (CITY) (STATE & ZIP CODE)
_______________________________________________________________________ # YEARS ______
(STREET) (CITY) (STATE & ZIP CODE)
LICENSE INFORMATION
Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license. I certify that I do not have more than one driver’s license, the information for which is listed below.
STATE LICENSE NO. TYPE EXPIRATION DATE
DRIVING EXPERIENCE
| CLASS OF EQUIPMENT | TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC | DATESFROM TO | APPROX NO. OF MILES (TOTAL) |
| STRAIGHT TRUCK | |||
| TRACTOR AND SEMI-TRAILER | |||
| TRACTOR TWO TRAILERS | |||
| OTHER |
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED)
| DATES | NATURE OF ACCIDENT(HEAD-ON, REAR-END, UPSET, ETC) | NUMBER FATALITIES | NUMBER INJURIES | CHEMICAL SPILLS |
| YES ___ NO ___ | ||||
| YES ___ NO ___ | ||||
| YES ___ NO ___ |
TRAFFIC CONVICTIONS ND FORFEITURES FR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
| DATE CONVICTED(MONTH/YEAR) | VIOLATION | STATE OF VIOLATION | PENALTY |
(ATTACH SHEET IF MORE SPACE IS NEEDED)
- Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES ___ NO ___
If yes, explain__________________________________________________________________________
- Has any license, permit or privilege ever been suspended or revoked? YES ___ NO ___
If yes, explain _________________________________________________________________________
CRIMINAL HISTORY
Have you ever been convicted of a criminal action? A conviction or court-martial is not necessarily a bar to employment. (Include court-martial convictions, but exclude minor traffic violations). YES ___ NO ___
If yes, please list date, charge, place, court, and action time:
EMPLOYMENT RECORD
(ATTACH SHEET IF MORE SPACE IS NEEDED)
Applicants that desire to drive in interstate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).
Must list the complete mailing address: street number and name, city, state and zip code
LAST EMPLOYER: NAME ___________________________________________________________________
ADDRESS ______________________________________________ PHONE __________________________
POSITION HELD ________________________ ________FROM _______ TO _______ SALARY ___________
REASON FOR LEAVING ____________________________________________________________________
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. ______________________________________________________________________________________________________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES _____ NO _____
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substance testing requirements as required by 49 CFR Part 40? YES _____ NO _____
SECOND LAST EMPLOYER: NAME ___________________________________________________________
ADDRESS ______________________________________________ PHONE __________________________
POSITION HELD ________________________ ________FROM _______ TO _______ SALARY ___________
REASON FOR LEAVING ____________________________________________________________________
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. ______________________________________________________________________________________________________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES _____ NO _____
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substance testing requirements as required by 49 CFR Part 40? YES _____ NO _____
THIRD LAST EMPLOYER: NAME _____________________________________________________________
ADDRESS ______________________________________________ PHONE __________________________
POSITION HELD ________________________ ________FROM _______ TO _______ SALARY ___________
REASON FOR LEAVING ____________________________________________________________________
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. ______________________________________________________________________________________________________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES _____ NO _____
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substance testing requirements as required by 49 CFR Part 40? YES _____ NO _____
TO BE READ AND SIGNED BY APPLICANT
I authorize you to make sure investigations and inquiries to 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. I understand that if I am hired by Presidential Limousines that my employment is at will and that the company reserves the right to terminate the relationship with or without cause and with or without notice at any time.
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 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 current/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 “
DATE APPLICANT’S SIGNATURE
This certifies that I completed this application, 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 required by the Federal Motor Carrier Safety Regulations.
