AHI SUPPLY 2800 N Gordon Alvin, TX 77511

Transcription

1 AHI SUPPLY 2800 N Gordon Alvin, TX Driver Application Equal access to programs, services and employment is available to all persons. Those applications requiring accommodation to the application and/or interview process should contact a representative of the Personnel Department. PLEASE PRINT Position applied for Date of application / / Rate of pay expected? Names of any relatives employed with AHI Referral Source: Advertisement Employee Relative Government Employment Agency Walk-in Private Employment Agency Other / Name of source Name First MI Last Address Street City State Zip *Note: If at the above residence less than three years, list below all residents for the past three years. Attach a separate sheet if necessary. Street City State Zip Street City State Zip Message, Voic , Mobile or Alternate Number: Home Telephone Number: Social Security Number: - - If necessary, the best time to call you at home is a.m./p.m. May we contact you at work?. If yes, please list work number and best time to call: ( ) If you are under 18 can you furnish a work permit? Have you filed an application here before? If yes, give date: Have you been employed here before? / / If yes, give dates:...from / / To / / Are you legally eligible for employment in this country? (Proof of U.S. Citizenship or immigration status will be required upon employment) Date available for work / / Type of employment desired:

2 Full-time Part-time Temporary Seasonal Are you currently employed? If not, how long since leaving last employment Are you on lay-off and subject to recall? Will you relocate if your job requires it? Will you travel? Do you understand the attendance requirements of the position? Are you able to meet the attendance requirements of the position? Will you work overtime if required? Have you plead guilty or no contest to a criminal charge in the past seven years? If yes, please explain: (Such plea may be relevant if job related, but does not bar you from employment) Driver s license number (if job related) State Have you ever been convicted of a felony If yes please explain * Conviction of a crime is not an automatic bar to employment-all circumstances will be considered. Educational Background (If job related) EDUCATION A. List last three (3) schools attended, starting with the most recent. B. List number of years completed. C. Indicate degree or diploma earned, if any. D. Grade Point Average or Class Rank and E. Major and minor field of study (if applicable). A. School B. Years Completed C. Degree/diploma D. GPA or class rank E. Major/Minor Languages Language Speak some Speak fluently Read Write

3 DRIVER EXPERIENCE & QUALIFICATION Social Security - - Drivers Licenses held in past 3 years must be shown. State License No. Class Endorsement(s) Expiration Date A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No B. Has any license, permit or privilege been suspended or revoked? Yes No C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes No * If you answered yes to A, B or C attach a statement giving details* DRIVING EXPERIENCE Class of equipment Straight truck Tractor/ semitrailer Twin Trailers LCV s Other Type of equipment (Van, Tank, Flat, etc.) From Dates To Approximate Total Miles List states operated in during last five years List special courses or training that will help you as a driver Accident Review for past 3 years (attach separate sheet of paper if more space is needed) Dates Nature or accident Fatalities Injuries (Head-on, rear-end, overturn, etc.) Last Accident Next Previous Next Previous Traffic Convictions and Forfeitures for the past 3 years other than parking violations Location Date Charge Penalty

4 Employment Record The U.S. Department of Transportation requires that driver applications show all employment for the past three years. They must also show commercial driver employment for the seven years immediately proceeding this three year period. Start with last or current position, including military experience, and work back. (Attach a separate sheet if necessary) Current/Recent Employer: Supervisor s Full Name: Full Address: Zip: Phone: Position Held: From: To: Salary: Reasons for leaving: Summarize worked performed: Current/Recent Employer: Supervisor s Full Name: Full Address: Zip: Phone: Position Held: From: To: Salary: Reasons for leaving: Summarize worked performed: Current/Recent Employer: Supervisor s Full Name: Full Address: Zip: Phone: Position Held: From: To: Salary: Reasons for leaving: Summarize worked performed: Current/Recent Employer: Supervisor s Full Name: Full Address: Zip: Phone: Position Held: From: To: Salary: Reasons for leaving: Summarize worked performed: Current/Recent Employer: Supervisor s Full Name: Full Address: Zip: Phone: Position Held: From: To: Salary: Reasons for leaving: Summarize worked performed: Is there any reason you that you wouldn t be rehired at one of your past jobs? If yes, list which job and explain reason:

5 Maintenance Experience & Qualifications List courses and training in maintenance work Job Function Indicate training and experience in the following: Drive line components Diesel Engine Tune-up and Rebuild Gas Engine Tuneup and Rebuild Tire Service Trailer Service Air Conditioning (cab) Refrigeration (cab) Formal Training (check) Years of Experience Area Body Work Electrical Repair Frame and Wheel Alignment Brakes Cooling System Inspections (state/federal) General Car Repair Formal Training (check) Years of Experience Shop Equipment Indicate training and experience in the following: Diagnostic Equip. Sheet Metal Equip. Frame & Axle Straightening Equip. Engine Rebuilding Diesel Injection Equip. Electric welder Oxyacetylene welder Paint spray gun Air Conditioning (cab) Refrigeration (cargo) ASE Certification(s) Formal Training (check) Years of Experience Area Tire servicing Wheel & balancing Machine Tire recapping Engine Dynamometer Magnetic Crack Detector Engine Analyzer Noise measuring Equip. Emissions/smoke testing Inspections (state/federal) General Car Repair Formal Training (check) Years of Experience

6 Personal References List the name and telephone number of three (3) business/work references who are not related to you and are not previous supervisors. If not applicable, list three schools or personal references that are not related to you. Name Telephone Years known List professional, trade, business, or civic associations and any offices held. (Exclude memberships that would reveal sex, race, religion, national origin, age, color, disability or other protected status.) Organization Offices Held I authorize Ahi Supply 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 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 interviews 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 employers will be contacted, the purpose of investigating my safety performance history as required by 49 CFR (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 employers and I cannot agree on the accuracy of the information Applicants Signature: Date:

7 Affirmative Action Voluntary Information To be completed by applicant. Not for interview purposes. To be filed separately from application. This information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Act or as necessitated by another federal law or regulation. As required, we comply with government regulations including Affirmative Action obligations where they apply. In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations, we ask that you complete this application data survey. Your cooperation is appreciated. Please be advised that this is NOT a part of your official application for employment. It is considered confidential information that will not be used in any hiring decision. Position(s) applied for Date of application / / REFERRAL SOURCE Advertisement Employee Relative Government Employment Agency Walk-in Private Employment Agency Other Name of Source (if applicable) APPLICANT INFORMATION Name: ( ) Last First Middle Area Code Phone Number Address: Street City State Zip Code Male Female Please check one of the following Equal Employment Opportunity Identification Groups: White Black (not of Hispanic origin) Hispanic American Indian/Alaskan Native Asian/Pacific Islander SPECIAL NOTICE To Vietnam Era Veterans, Disabled Veterans and individuals with physical or mental disabilities: Government contractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disabled veterans, veterans of the Vietnam era and qualified handicapped individuals. You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation. This information will be considered confidential. Refusal to provide this information will not adversely affect your consideration for employment. If you wish to be identified, please check if any of the following are applicable: Vietnam Era Veteran (served between ) Disabled Veteran Individual with a disability

8 Request for check of driving record I hereby authorize you to release the following information to AHI SUPPLY (Prospective Employer) for purposes of investigation as required by Sections and of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. Applicants Signature Date In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law , as amended by the Consumer Credit Reporting Act of 1996 (title ll, Subtitle D, Chapter 1, of Public Law ), I hereby certify the following: 1. The consumer (applicant) has authorized in writing the procurement of this report; 2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes; 3. The information requested below will be used for a permissible purpose and be used for no other purposes; 4. The information being obtained will not be used in a violation of any federal or state equal opportunity law or regulation; and 5. Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency. I also hereby certify that this report request and the above applicant s release notice meet the definition of permissible uses of state motor vehicle records under the provisions of the Driver s Privacy Protection Act of (Signature of Requester) (Date) NAME OF APPLICANT/DRIVER ADDRESS (Number & Street) (City) (State) (Zip Code) DATE OF BIRTH SSN LICENSE NO. REQUESTED BY Ahi Supply NAME OF COMPANY 2800 N Gordon ADDRESS Alvin, TX CITY/STATE TYPE NAME HR Assistant/Receptionist TITLE SIGNATURE

9 Safety performance History Records Request To Be Completed by Prospective Employee (Print Name) I First M.I. Last Social Security Number Date of Birth Hereby Authorize to release and forward the information requested by section 3 of this document concerning all employment, Drug/Alcohol and Controlled Substances Testing, and Safety Performance History records within the previous 3 years from. (Date of employment application) Prospective Employer: AHI Supply Attention: HR Dept. Telephone: Street: 2800 N Gordon City, State, Zip: Alvin, TX In compliance with 40.25(g) and (h), release of this information must be made in a written form that ensures confidentiality, such as fax, , or letter. Prospective employer s confidential fax number: Prospective employer s confidential address: TO BE COMPLETED BY PREVIOUS EMPLOYER The applicant named above was employed by us. Yes No Employed as from (m/y) to (m/y) 1. Did He/She drive motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semi trailer Bus Cargo Tank Doubles/Triples other 2. Is He/She eligible for rehire with your company? Yes No If you answered no can you please elaborate why? If there is no safety performance history report, check here, sign below and return. ACCIDENTS: Complete the following for any accidents included on your accident register (390.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or check here if there is no accident register data for this driver. Date Location No. of Injuries No. of Fatalities Hazmat Spill Please provide information concerning any other accidents involving the applicant that were reported to government agencies of insurers or retained under internal company policies: Signature: Title: Date:

10 TO BE COMPLETED BY PREVIOUS EMPLOYER If driver was not subject to Department of Transportation testing requirements while employed by this employer, please check here, fill in the dates of employment from to, complete bottom of this Section, sign and return. Driver was subject to Department of Transportation testing requirements from to. 1. Has this person had an alcohol test with a result of 0.04 or higher alcohol concentration? Y N 2. Has this person tested positive or adultered or substituted a test specimen for controlled substances? Y N 3. Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test? Y N 4. Has this person committed other violations of Subpart B of Part 382 or Part 40? Y N 5. If this person has violated a DOT drug and alcohol regulation, did this person fail to undertake or complete a program prescribed by a Substance Abuse Professional (SAP) in your employ? Y N 6. For a driver who successfully completed a SAP s rehabilitation referral and remained in your employ, did this driver subsequently have an alcohol test result of 0.04 greater, a verified positive drug test, or refuse to be tested? Y N In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previous employers in the previous 3 years prior to the application date shown above. Name: Company: Street: City, State and Zip: Telephone: Completed By: Date: