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  • 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, veteran status, non-job related disability, or any other protected group status.

  • TO BE READ AND SIGNED BY APPLICANT

    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 liabiloity 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 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 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: ________________

  • FOR COMPANY USE ONLY

    ---------------------------------------- PROCESS RECORD ----------------------------------------

    APPLICANT: _____ POSITION OFFERED ____ APPLICANT REJECTED

    DATE OF HIRE: ___________________  OFFICE ASSIGNED: ___________________

    SIGNATURE OF INTERVIEWER(S): _______________________________________

    -------------------------------- TERMINATION OF EMPLOYMENT --------------------------------

    DATE TERMINATED: ______________________

    REASON: ____ VOLUNTARY QUIT ____ INVOLUNTARY TERMINATION ____ OTHER

    REHIRE STATUS: ____ YES ____ NO

    OFFICE RELEASED FROM: _____________________________________________

    MANAGER RELEASING EMPLOYEE FROM POSITION: ________________________

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  • List your addresses of residency for the past 3 years:

  • How long?

  • How long?

  • How long?

  • How long?

  • EMPLOYMENT HISTORY

  • NO GAPS IN 10 YEAR HISTORY  / IF YOU WERE UNEMPLOYED, YOU MUST LIST THE DATES.

    List complete mailing address, street number, city, state and ZIP.

    (NOTE: List employers in reverse order starting with the most recent.)


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  • NO GAPS IN 10 YEAR HISTORY  / IF YOU WERE UNEMPLOYED, YOU MUST LIST THE DATES.

  •  -
  • NO GAPS IN 10 YEAR HISTORY  / IF YOU WERE UNEMPLOYED, YOU MUST LIST THE DATES.

  •  -
  • NO GAPS IN 10 YEAR HISTORY  / IF YOU WERE UNEMPLOYED, YOU MUST LIST THE DATES.

  •  -
  • NO GAPS IN 10 YEAR HISTORY  / IF YOU WERE UNEMPLOYED, YOU MUST LIST THE DATES.

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  • EXPERIENCE & QUALIFICATIONS - OTHER

  • EDUCATION

  • TO BE READ AND SIGNED BY APPLICANT

    My signature below 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.

    SIGNATURE: _______________________________________   DATE: ________________

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