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Fields With * are Mandatory |
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| Position Applied for * |
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Date of Application * |
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| Name * |
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Social Security Number * |
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| List address for past 3 years |
| Current Address * |
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| Do you have the legal right to work in the United States? * |
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Date of Birth? (MM-DD-YY)
(Required for Commercial Drivers)* |
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Can you provide proof of age? * |
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| Have you worked for this company before?* |
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| Are you currently employed? * |
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| EMPLOYMENT HISTORY |
| Most Recent Employer * |
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| IF NO ACCIDENTS HAVE OCCURED FOR THE PAST 3 YEARS, PLEASE INDICATE NONE IN TOP FIELDS ONLY |
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| TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS. IF NONE, PLEASE INDICATE NONE IN TOP FIELDS ONLY |
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| DRIVER QUALIFICATIONS AND EXPERIENCE |
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A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes
No
B.
Has a license, permit or privilage ever been suspended or revoked?
Yes
No
IF THE ANSWER TO EITHER A OR B IS YES, PLEASE GIVE DETAILS *
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TO BE READ BEFORE SUBMITTING
This certifies that this application was completed by me, and that all entries and information
are true and complete to the best of my knowledge.
I authorize you to make such
knowledge, investigations and inquiries of my personal, employment, financial, medical or drug and
alcohol history and other related matters as may be necessary in arriving at an employment
decision. (General inquiries regarding medical history will be made, only if after a
conditional offer of emploment has been extended.) I hereby release employers, schools,
healthcare 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 interview ( s) may
result in discharge. I understand, also, that I am required to abide by all rules and regulations
of Stranco, Inc. |
| Date * |
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| APPLICANT'S NAME * |
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SOCIAL SECURITY NUMBER * |
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YOU ARE AUTHORIZED TO FURNISH STRANCO, INC. ALL INFORMATION REGARDING MY SERVICES, CHARACTER, AND CONDUCT WHILE IN YOUR EMPLOYMENT. YOU ARE
RELEASED FROM ANY/ALL LIABILITY WHICH MAY RESULT FROM PROVIDING SUCH INFORMATION. I ALSO AUTHORIZE YOU TO PROVIDE STRANCO, INC. WITH
INFORMATION IN ACCORDANCE WITH SECTION 382.413 OF THE FMCSR REGARDING ALCOHOL TESTS WITH A CONCENTRATION OF 0.04 OR GREATER; POSITIVE
CONTROLLED SUBSTANCE TEST RESULTS, REFUSALS TO BE TESTED, ANY VIOLATIONS OF DOT AGENCY DRUG AND ALCOHOL TESTING REGULATIONS,
DOCUMENTATION OF COMPLETED DOT RETURN TO DUTY REQUIREMENTS, IF APPLICABLE; AND ANY DRUG AND ALCOHOL INFORMATION RECEIVED FROM
PREVIOUS EMPLOYERS WITHIN THE THREE (3)YEARS PRECEDING THE DATE OF THIS SIGNED RELEASE. I HEREBY AUTHORIZE STRANCO, INC. TO RELEASE ANY SUCH
INFORMATION TO ANY OF ITS PERSONNEL WHOSE DUTIES REQUIRE THEM TO ASSESS THIS APPLICATION OR TO MAKE ANY RECOMMENDATIONS OR DECISIONS
WITH RESPECT TO IT. I FURTHER AUTHORIZE STRANCO, INC. TO PHOTOCOPY THIS FORM AS MANY TIMES AS REQUIRED TO OBTAIN INFORMATION FROM ALL
PREVIOUS EMPLOYERS. A COPY OF THIS FORM IS VALID. |
| APPLICANT'S SIGNATURE * |
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DATE * |
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