EMPLOYMENT APPLICATION APPLICANT INFORMATION Last Name First Name Middle Initial Date Street Address Apartment/Unit # City State Zip

Transcription

1 1077 Route 119 Highway North Indiana, PA Phone: Fax: Indiana, PA Barnesville, OH Waynesburg, PA Butler, PA EMPLOYMENT APPLICATION APPLICANT INFORMATION Last Name First Name Middle Initial Date Street Apartment/Unit # City State Zip Home Phone Cell Phone Date Available Social Security Number Desired Salary Position Applying For How did you hear about us? Please be specific. Location Are you a citizen of the United States? YES NO If no, are you authorized to work in the United States? YES NO Have you ever worked for this company? YES NO If so, when? If so, what position? Which employment status are you interested to work: Full-time Part-time Temporary Seasonal Are you available to work: Are you 18 years of age or older? YES NO DAY SHIFT NIGHT SHIFT ALL SHIFTS Have you ever been convicted of a felony? YES NO If yes, please explain. Such conviction does not necessarily prevent you from employment. FORCE INC. is an equal opportunity employer. EDUCATION High School From To Did you graduate? YES NO Degree College From To Did you graduate? YES NO Degree Other From To Did you graduate? YES NO Degree MILITARY SERVICE Have you ever served in the U.S. Military? YES NO Enlisted To Enlisted From Branch? Type of discharge? Rank at the time of discharge? If other than honorable discharge, please explain. REFERENCES Please list three professional references Name Name Name Title Phone Title Phone Title Phone

2 PREVIOUS EMPLOYMENT Please list the last three employers Company Company Phone Supervisor Supervisor s Title Title/Position Duties Employed To Employed From Starting Salary Ending Salary Reason for Leaving? May we contact this company/supervisor for a reference? YES NO Company Company Phone Supervisor Supervisor s Title Title/Position Duties Employed To Employed From Starting Salary Ending Salary Reason for Leaving? May we contact this company/supervisor for a reference? YES NO Company Company Phone Supervisor Supervisor s Title Title/Position Duties Employed To Employed From Starting Salary Ending Salary Reason for Leaving? May we contact this company/supervisor for a reference? YES NO DISCLAIMER AND SIGNATURE READ THIS SECTION PRIOR TO PROVING SIGNATURE BELOW ADDITIONAL INFORMATION In consideration of my employment, I agree to conform to the rules and regulations of this facility. I understand that my employment can be terminated at any time and for any reason, at the option of either the facility or myself. I understand that no one has any authority to enter into any agreement for employment for a specified period of time or to make any agreement contrary to the foregoing, except for a written employment agreement signed by an administrative representative of this facility. I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions may disqualify me from further consideration for employment and will result in discharge even if discovered at a later date. I also understand any offer of employment is contingent upon results of post-offer medical examination which includes a drug screening and background check. I hereby authorize persons, schools, my current employer (if applicable) and previous employers and organizations named in this application (and accompanying resume, if any,) to provide this facility and all affiliates with any relevant information regarding an employment decision, and I release all such persons from any liability regarding the provision or use of such information. Equal Employment Opportunity Statement: FORCE INC. is an equal opportunity employer. No person shall be discriminated against on account of race, color, religious creed, national origin, ancestry, sex, disability, or status as a veteran or any other unlawful basis. Employment decisions will be based on the principles of equal opportunity. All personnel actions (recruiting, hiring, training, promotion, compensation, etc.) are administered without regard to any characteristic protected by state, federal, or local law, assuming said characteristic does not interfere with the performance of essential job functions. Reasonable accommodations will be made for disabilities and religious beliefs. Please inform us of any necessary accommodations to the application process. Signature Date

3 1. Do you have a commercial driver s license? Employment Application Addendum If yes, circle one: Class A Class B 2. Have you had any preventable accidents resulting in a fatality while operating a commercial motor vehicle in your lifetime? 3. Have you had more than ONE non-preventable accident while operating a commercial motor vehicle in the last 3 years? 4. Have you had more than TWO moving violations while operating a personal or commercial motor vehicle in the last 3 years? 5. Have you had any serious traffic violations while operating a commercial motor vehicle in the last 3 years? 6. Have you had any preventable accidents while operating a commercial motor vehicle in the last 3 years? 7. Have you ever been convicted for a DUI, DWI, OUI, or reckless driving with alcohol/drugs involved within the last 10 years? 8. Have you refused or had any positive drug test results/alcohol test results, either DOT regulated or non-regulated, in the past 5 years? 9. Have you had any preventable D.O.T. recordable accidents (fatality, disabled vehicle required towing, requiring medical care) while operating a commercial motor vehicle in the last 10 years? Signature of Applicant / Employee Printed Name of Applicant/ Employee Date

4 1077 Route 119 Highway North Indiana, PA Phone: Fax: Indiana, PA Barnesville, OH Waynesburg, PA Butler, PA Drug and Alcohol Policy Certification 1. The drug and alcohol policy covers all Force Incorporated s employees including CDL Drivers who fall under 49 CFR, Parts 382 of the U.S. Department of Transportation. 2. An illegal drug is: a. Drugs or controlled substances of which the possession or use of is unlawful b. Drugs or controlled substances which are legally obtained but which have been obtain illegally c. Prescribed drugs not being used for prescribed purposes or in a prescribed manner 3. The manufacture, distribution, dispensation, possession, sale or use of illegal drugs by Force Incorporated s employees on or off the company premises is prohibited. 4. The use, possession, sale or distribution of alcohol, or being under the influence of alcohol on company premises or customer premises is prohibited. 5. All employees are required to undergo drug testing for: pre-employment, random selection, post-accident, reasonable suspicion, return-to-duty, and follow up testing. All employees are required to undergo alcohol testing under circumstances of post-accident, reasonable suspicion, return-to-duty and follow up. 6. Force Incorporated will pay all fees for pre-employment, random, post-accident and reasonable suspicion testing. 7. Any employee testing positive for drugs and/or alcohol and who is continuing employment at Force Incorporated is responsible for fees for any additional testing and for the fees for any required rehabilitation which are not covered by Force Incorporated s insurance provider. The employer is not responsible for the fees for any additional testing or rehabilitation for employees who are terminated. 8. Any employee who has been informed that he/she has tested positive for drugs and/or alcohol who performs any safety sensitive function for Force Incorporated is terminated from the moment they begin to drive or perform the function. 9. Whether an employee who tests positive will be terminated or is suspended from duty without pay until he/she has undergone rehabilitation is at the sole discretion of the employer. 10. Any employee who refuses to take his/her drug and/or alcohol test will be terminated. A refusal may consist of not proceeding to the testing site in a timely manner, not cooperating during the collection process, or any attempt at adulteration of the testing samples. 11. All employees must sign approval forms agreeing to the testing and authorizing the release of test results to Force Incorporated s personnel representative and higher management. 12. For CDL drivers, drug testing may require the provision of urine or any sample designated under US. Department of Transportation regulations. For other employees drug testing may require the provision of any sample which is considered standard in the drug and alcohol testing industry. 13. Alcohol testing required breathing in a Breathalyzer or a saliva test or any other method designated under 49 CFR, Parts 382 and 655 of the Department of Transportation. 14. Force Incorporated has a zero tolerance for alcohol use. Thus, the alcohol limits and consequences are: a..02 to hours suspension without pay b..04 or higher suspension without pay with a termination option at the sole discretion of the employer.

5 15. Any employee testing.02 to.04 will be suspended from duty for the first offense. At his/her expense, the employee will be required to have a return-to-duty alcohol test with a negative result before returning to duty. Such an incident will serve as the same as written notice and the second occurrence will have the same consequences as a.04 or higher reading. 16. I understand that under Force Incorporated s policy, I may be tested at any time for drug and/or alcohol abuse whether the tests and/or circumstances is listed under Department of Transportation regulation or not. I understand that the procedures for such tests will follow the standard procedures in the drug and alcohol testing industry. 17. This drug and alcohol policy is implemented for the safety of the general public and for the safety of Force Incorporated s employees and clients. 18. I have been given the opportunity to read Force Incorporated s drug and alcohol policies and procedures. I have also been given the opportunity to ask questions and have received sufficient answers about Force Incorporated s policies and procedures on drug and alcohol abuse. 19. Information on this drug and alcohol program is available from the staff at the drug and alcohol consortium or through the designated representatives of Force Incorporated. This signature certifies that I am aware compliance with this policy is condition of employment at Force Incorporated and I agree to abide by Force Incorporated s drug and alcohol policy. 20. If employee leaves Force Incorporated on their own terms with six (6) months they will be responsible for reimbursing Force Incorporated the cost of the Drug Screening. This cost is roughly $ for a Drug Screening Test. Signature Witness Date Date

6 1077 Route 119 Highway North Indiana, PA Phone: Fax: Indiana, PA Barnesville, OH Waynesburg, PA Butler, PA Date: Dear Force Incorporated: Consumer reports may be obtained as part of Force Incorporated s evaluation of my job application/employment. The reports may be procured by Force Incorporated via DOT websites, and may include my driving record, an assessment of my insurability under the company s insurance coverage. By signing this disclosure, I hereby authorize Force Incorporated to obtain such motor vehicle reports on me from time to time, as it deems appropriate to evaluate my insurability. Sincerely, Applicant/Employee Signature Date of Birth Applicant/Employee Name (PRINTED) Driver License Number Social Security Number