Driver s Application for Employment

Transcription

1 2300 T Street N.E. Washington, DC Driver s Application for Employment Position(s) applied for Date of Application / / Referral Source Name: A KANE FAMILY COMPANY Advertisement Employee Walk - in Private Employment Agency Name of source (if applicable) Last Address: Social Security # Street City-State-Zip Code Telephone # ( ) Cell Phone # ( ) Address Relative Internet Government Employment Agency Date of Birth (Required for Commercial Drivers by U.S. DOT (b)(2) / / Can you provide proof of age?... Yes No First Middle If necessary, best time to call you at home is May we contact you at work? If yes, work number and best time to call Have you submitted an application here before? If yes, give date(s) and position(s) Have you ever been employed here before? If yes, give dates... : Yes No...( ) : PM... Yes No... Yes No...From / / To / /... Yes No... Yes No... / / What is your desired salary?...$ Are you able, with or without reasonable accommodations, to perform the essential job functions? Are you legally eligible for employment in the U.S.? Date available for work Type of employment desired Full-Time Part-Time AM PM AM Driver s License number State List your addresses of residency for the past 3 years. Current Address: Street City Previous Addresses: State Zip Phone How Long? Street City, State, Zip How Long? Street City, State, Zip How Long? Street City, State, Zip How Long? Street City, State, Zip How Long? INTERNATIONAL LIMOUSINE SERVICE, INC. IS AN EQUAL OPPORTUNITY EMPLOYER AND SELECTS INDIVIDUALS BEST MATCHED FOR THE JOB BASED UPON JOB RELATED QUALIFICATIONS REGARDLESS OF AGE, RACE, COLOR, SEX, RELIGION, NATIONAL ORIGIN, DISABILITY (PHYSICAL OR MENTAL), OR MARITAL STATUS. ILS IS A VEVRAA FEDERAL CONTRACTOR AND AN EQUAL OPPORTUNITY EMPLOYER OF INDIVIDUALS WITH DISABILITIES AND OF PROTECTED VETERANS.

2 Employment History

3 List all accidents for the past 3 years or more (attach sheet if more space is needed). If none, write none. DATES MOST RECENT NEXT RECENT NEXT RECENT TYPE OF VEHICLE NATURE OF ACCIDENT FATALITIES INJURIES HEAD-ON, REAR-END, UPSET, ETC. (EXPLAIN) (EXPLAIN) Yes No Yes No Yes No Yes No Yes No Yes No Traffic convictions for the past 3 years (other than only parking violations). If none, write none. LOCATION DATE CHARGE PENALTY Educational Background (ATTACH SHEET IF MORE SPACE IS NEEDED) CIRCLE HIGHEST LEVEL COMPLETED: HIGH SCHOOL: COLLEGE: LAST SCHOOL ATTENDED (NAME) (CITY) (STATE) Experience and Qualifications - Driver DATES LICENSE NO. TYPE ENDORSEMENTS EXPIRATION DATE ALL DRIVERS LICENSES HELD IN PREVIOUS 3 YEARS A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? B. Has any license, permit, or privilege ever been suspended or revoked? C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Administration (If you answered Yes to any above, attach statement giving details.) Yes Yes Yes No No No Driving Experience - If none, write none. CLASS OF EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.) FROM DATES TO AREAS TRAVELED APPROX. NO OF MILES Straight Truck Tractor and Semi-Trailer Tractor - Two Trailers Passenger Vehicle Other LIST STATES OPERATED IN FOR LAST FIVE YEARS LIST SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

4 PLEASE READ CAREFULLY BEFORE SIGNING EMPLOYMENT APPLICATION AND AGREEMENT I understand that completion of this application does not indicate that there are any positions open and does not in any way obligate the Company to hire me or to offer me a job. I also understand this application is current for only thirty (30) days. If I have not been contacted within thirty (30) days and still wish to be considered for employment, I must fill out a new application. I understand that if hired, my employment with the Company would be for an indefinite period of time and may be terminated by me or the Company at any time for any or no reason. Likewise, no oral statements or assurances by any person within the Company will constitute an employment contract which can only be entered into by an individualized written agreement signed by me and an officer of the Company. I agree that, if I am hired, I will conform with all company policies and procedures and understand that the Company may modify, amend, and/or revoke and of its employment policies, practices, and benefits without prior written notice or my consent. Furthermore, I agree that, if I am hired, the Company shall have the right to withhold all or part of my wages to offset any financial liability I may have to the Company, including loss of product through theft, carelessness or negligence. I understand that if I am hired, I will be a probationary employee during the 90-day introductory period and that after completion of my probation period, I understand that the relationship shall continue to be an employment at-will relationship, terminable at any time with or without cause or reason by either me or the Company. I understand that the company has a policy that provides for a drug and alcohol free work place and that I must not test positive for controlled substances or alcohol as a condition of employment or continued employment. I hereby consent to the submission of my urine specimen to the certified laboratory designated by the Company, to the analysis of the specimen for controlled substances and alcohol, and to the release of the test results from that analysis to the Medical Review Officer designated by the Company. I hereby release the clinics, testing laboratories and the company and any employees and/or agents thereof, from any and all claims or causes of action resulting from the collection and or testing procedures and from disclosure of these results. I hereby further agree to waive any physician/patient privileges that may otherwise exist with respect to the confidentiality of the results of such testing. I further understand that I am subject to drug and alcohol testing as a condition of ongoing employment and my failing to consent to the procedures to perform such testing when applicable will be regarded as a positive test result and will result in my termination from employment. I understand that if I am hired, I may be required at any time to submit to a drug test, alcohol test, and/or medical examination, to the extent permitted by law, conducted by a licensed physician selected by the Company at Company expense. I hereby give a continuing authorization to any hospital or other health care facility and to any physician or other person conducting such medical examinations and/or test to furnish the Company or its designated agent, any medical records or medical information as may be relevant and necessary including testifying at a deposition or otherwise cooperating in the investigation of any claim against the Company or the insurance carriers of the Company, including any claim I may have for workman s compensation. I understand that the Company reserves the right to use any method of investigation which, in its sole discretion, it deems reasonable and necessary to determine whether any employee has engaged in conduct warranting disciplinary action. As a condition of employment, if hired, I agree to cooperate in any such investigation. As a condition of my employment, I voluntarily agree to cooperate in submitting to any urine or blood tests requested by the Company, as well as any searches of my person or property while employed by the Company, and I recognize that refusal to cooperate in such tests or searches would be grounds for discipline, including termination. ****Authorization to obtain consumer report**** I certify that I have received a written notification that the Company may obtain a consumer report on me. This report may be used in connection with my application for employment and for other employment related purposes, including post-employment issues. I authorize the Company to obtain this report. I understand that the Company may investigate my work and personal history. I authorize all person, schools, companies, corporations, credit bureaus and law enforcement agencies to supply any information concerning my background and release them from any liability and responsibility from their doing so. I also authorize the Company to provide truthful information concerning my employment with the Company to future prospective employers and I agree to hold the Company and its employees harmless for providing such information.federal law prohibits the employment of unauthorized aliens. If hired, I agree to comply with the law by signing all required forms and by submitting satisfactory proof of employment authorization and identity within three (3) days of being hired. Failure to do so will result in immediate termination. For Maryland applicants only: Under Maryland law, an employer may not require or demand any applicant for employment or prospective employment or any employee to submit to or take polygraph, lie detector or similar test or examination for employment or continued employment. Any employer who violates this provision is guilty of a misdemeanor and subject to a fine not to exceed $ SIGNATURE OF APPLICANT DATE I certify that I have read and understand the above paragraphs. I further certify that all information submitted on this application is true and correct to the best of my knowledge. I understand that any false information, omission, or misrepresentations of facts called for in this application or in interviews may be cause for the denial of my application or, if I am employed, discharged at any time. I also affirm that I have a genuine intent and no other purpose in applying for a position with the Company. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENTS AND AGREEMENTS. PRINT NAME SIGNATURE OF APPLICANT DATE

5 Affirmative Action Voluntary Information We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria. To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application. In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated. Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations. PLEASE PRINT Position(s) applied for Date / / Referral Source Walk-in Government Employment Agency Private Employment Agency Employee Relative School Advertisement - Source Other Name of person who referred you (If applicable) Applicant Information Name Telephone # ( ) Address Male Last Female Please check one of the following Equal Employment Opportunity Identification Groups: White (not of Hispanic origin) Asian/Pacific Islander Disabled American Indian/ Alaskan Native Hispanic Veteran Black (not of Hispanic origin) Multiracial (having parents of different races) Protected Veteran For Administrative Use Only Position(s) applied for Available Not Available Other positions considered for First Middle Street City State Zip Code Hired Yes No Position hired for Date of hire / / From the EEO job classifications listed below, which one best describes the position filled? Notes Officials Sales Workers Operatives (semi-skilled) Professionals Office and Clerical Workers Laborers (unskilled) Technicians Craft Workers (skilled) Service Workers Completed by Date / /

6 This page is intentionally blank

7 A KANE FAMILY COMPANY 2300 T Street N.E. Washington, DC NOTICE AND AUTHORIZATION Concerning Consumer and Investigative Consumer Reports This form, which you should read carefully, has been provided to you because our Company may request consumer reports or investigative consumer reports in connection with your application for employment, or at any time during the course of your employment with the Company, if any, for purposes of evaluating your suitability for employment, promotion, reassignment or retention as an employee. Additionally, in the event that claims or disputes between you and the Company are filed with any third parties, the Company may request consumer reports or investigative consumer reports for purposes of evaluation and response, regardless of whether you remain in the employ of the Company at the time such claims or disputes arise. The types of reports that may be requested from consumer reporting agencies under this policy include, but are not limited to, credit reports, criminal records checks, court records checks, driving records, and/or summaries of educational and employment records and histories. The information contained in these reports may be obtained by a consumer reporting agency from public record sources or through personal interviews with your coworkers, neighbors, friends, associates, current or former employers, or other personal acquaintances. I understand that the Company may investigate my work and personal history. I authorize all person, schools, companies, corporations, credit bureaus and law enforcement agencies to supply any information concerning my background and release them from any liability and responsibility from their doing so. I also authorize the Company to provide truthful information concerning my employment with the Company to future prospective employers and I agree to hold the Company and its employees harmless for providing such information. AUTHORIZATION I have carefully read and understand this notice and authorization form and, by my signature below, consent to the release of consumer or investigative consumer reports, as defined above, to the Company (1) in conjunction with my application for employment, (2) during the entire course of my employment, if any, and (3), after any such employment ends. I further understand that any and all information contained in my job application or otherwise disclosed to the Company by me before, during or after my employment, if any, may be utilized for the purpose of obtaining the consumer reports or investigative consumer reports requested by the Company and confirm that all such information provided in connection with my job application is true and correct. I understand and acknowledge that nothing in this notice and authorization is intended to be, or is, an offer of employment or a promise of continued employment. If employed by the Company, my employment will not be for a specified period of time and can be terminated at any time for any reason, with or without cause or notice, by me or by the Company. The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. I understand that my date of birth is required by some governmental agencies as a prerequisite in releasing the requested information to the Company and/or its designated agent and that my date of birth will not be used in any other way in the employment process other than the release of the information as described above. Full Name (no nicknames): S.S.N.: Other names previously used and when (maiden names, nicknames, etc.): Date of Birth: Driver s License Number State: Current: ADDRESS Street City County State Zip Code From To Previous: Previous: Previous: Applicant Signature: Date:

9 A KANE FAMILY COMPANY 2300 T Street N.E. Washington, DC DRUG AND ALCOHOL Consent and Release Policy Having been advised that International Limousine Service, Inc. has a policy that provides for a drug and alcohol free work place, I understand that I must not test positive for controlled substances as a condition of employment or as a condition of providing leased driving services. I hereby consent to the submission of my urine specimen to the certified laboratory designated by the Company, to the analysis of the specimen for controlled substances as provided by federal requirements, and to the release of the test results from that analysis to the Medical Review Officer designated by the Company. Additionally, in accordance with DOT regulations and company policy, I understand that I may be subject to drug and alcohol testing as a condition of on-going employment or as a condition of leased driving services, and hereby consent to the procedures to perform such testing when applicable. I understand that I may request, at my expense, to have a specimen retested. Further, I hereby release the clinics, testing laboratories and International Limousine Service, Inc. and any employees and/or agents thereof, from any and all claims or causes of action resulting from the collection and/or testing procedures and from disclosure of these results. I hereby further agree to waive any physician/patient privilege that may otherwise exist with respect to the confidentiality of the results of such testing. Printed Name: Signed: Date:

11 A KANE FAMILY COMPANY 2300 T Street N.E. Washington, DC APPLICANT S NOTES INTERVIEWER S COMMENTS