Driver/Operator/Laborer Employment Application

Full Name:

Email Address:

Present Address:

How Long?:

If resided at above address for less than 3 years, please complete below until you complete 3 years of residency history:

Previous Address:

Cell Phone Number:

Home Phone Number:

Do you have a valid Drivers License?:

If Yes, What Class?:

Issuing State:

License Number:

Expiration Date:

CDL Section

NOTE: Information required in accordance to FMCSA 391.21(b)(2)

SSN:

Date of Birth:

Years of Truck Driving Experience:

Endorsements and Expiration Dates:

Types of Trucks Operated:

Last time you drove a Semi-Truck:

Approximate Semi-Truck Driving Hours:

Have you ever received a denial, revocation, or suspension of any license, permit or privilege to operate a motor vehicle?

If yes, please provide in detail the facts and circumstances relating to this:

Have you been involved in any motor vehicle accidents during the past 3 years?

If yes, please complete the following in detail and provide any additional information necessary

Accident 1

Date:

Nature of Accident:

Fatalities/Personal Injuries:

Accident 2

Date:

Nature of Accident:

Fatalities/Personal Injuries:

Have you ever been convicted of a misdemeanor or felony?

If yes, please provide date, city/state and disposition:

NOTE: A conviction will not necessarily disqualify you from employment. Each conviction will be judged on its own merits with respect to time, circumstance and seriousness.

Have you been refused any type of insurance or been denied bonding?:

Have you been convicted or forfeited bond or collateral for a motor vehicle violation (other than parking violations) during the past 3 years?

If yes, please complete the following in detail and provide any additional information necessary:

Violation 1

Date:

Description:

Violation 2

Date:

Description:

Employment History

Are you currently employed?:

If yes, may we contact your employer?:

Please list employment history beginning with the most current employment. A minimum of 3 years history required.

Employer 1

From:

To:

Company Address & Telephone:

Reason for Leaving:

Salary/Wages Per Hour:

Were you subject to FMCSR's?:

Employer 2

From:

To:

Company Address & Telephone:

Reason for Leaving:

Salary/Wages Per Hour:

Were you subject to FMCSR's?:

Employer 3

From:

To:

Company Address & Telephone:

Reason for Leaving:

Salary/Wages Per Hour:

Were you subject to FMCSR's?:

Employer 4

From:

To:

Company Address & Telephone:

Reason for Leaving:

Salary/Wages Per Hour:

Were you subject to FMCSR's?:

Education

High School

Name of School

Graduate Year:

Degree & Major:

College

Name of School:

Graduate Year:

Degree & Major:

Trade/Specialized School

Name of School:

Graduate Year:

Degree & Major:

Other

Name of School:

Graduate Year:

Degree & Major:

References

Reference 1

Name of person not living with you:

Relationship:

Address:

Phone Number:

Reference 2

Name of person not living with you:

Relationship:

Address:

Phone Number:

Job Requirements

The requirements of this job may include lifting weights of up to 110 lbs. repetitively and operating tools/equipment on-site (other requirements as appropriate). Do you have any physical attributes which would prevent your being able to accomplish these tasks?

Are you physically fit to perform manual labor such as shovel, operate a vibraplate, carry concrete blocks on a daily basis?

Terms

Please read the following paragraphs carefully. Submitting this form indicates your understanding and acceptance of each of these paragraphs.

I authorize any of the personal or organizations referenced in this application to provide JM Construction Inc.
with information concerning any previous employment, education, or any other information they
might have, personal or otherwise, with regard to any of the subjects covered by this application, and
I release all such parties from all liability for any damage which may result from furnishing such
information to JM Construction Inc.
I understand the information that I have provided is in accordance with section FMCSA 391.21 paragraph (b)(10) and
that my prior employers may be contacted for the purpose of investigating my saftey performance history information
as required by paragraphs (d) and (e) of 391.23. I understand that I have rights in accordance to 391.23(i) regarding
information obtained from prior employers. (APPLICABLE TO CDL APPLICANTS)
I consent to a physical examination, which includes a drug test, either prior to commencement of
employment or after I have become employed, as deemed necessary by the JM Construction Inc.
I consent to a criminal background check prior to employment with JM Construction Inc.
I hereby declare the information provided by me in this application is true and complete, and I
understand that falsification and/or omissions of this information is grounds for refusal to hire or, if I have
been hired, for termination.
I further acknowledge that if I am employed by JM Construction Inc., my employment will be at will,
and may be terminated with or without cause, and with or without notice at any time, by me or by JM Construction Inc.

Accepted terms:

Please leave this field empty.