Fields With * are Mandatory Position Applied for * Date of Application * Name * First Last Middle Social Security Number List address for past 3 years Current Address * Street City State -Select-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Phone #: (Home) (Cell) How Long? Do you have the legal right to work in the United States? * YesNo Date of Birth? (MM-DD-YY) (Required for Commercial Drivers) * Can you provide proof of age? * YesNo Have you worked for this company before? * YesNo Where? * Positions * Dates: * FROM TO Are you currently employed? * YesNo If not, how long since leaving last employment? * How did you hear about Stranco?* -Select-InternetNews PaperBy Friend Is there any reason you might be unable to perform the functions of the job for which you have applied ?If yes, please explain: * Expected Rate of Pay * Employment History Most Recent Employer * Name Position Held FROM: * MO Select MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember YR TO: * MO Select MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember YR Address City State -Select-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Phone# Type Of equip. operated/pulled? Contact Person IF NO ACCIDENTS HAVE OCCURED FOR THE PAST 3 YEARS, PLEASE INDICATE NONE IN TOP FIELDS ONLY LAST ACCIDENT DATES NATURE OF ACCIDENT FATALITIES FATALITIES INJURIES Previous DATES NATURE OF ACCIDENT FATALITIES INJURIES Previous DATES NATURE OF ACCIDENT FATALITIES INJURIES TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS. IF NONE, PLEASE INDICATE NONE IN TOP FIELDS ONLY LOCATION * DATE * CHARGE * PENALITY * LOCATION DATE CHARGE PENALITY LOCATION DATE CHARGE PENALITY DRIVER QUALIFICATIONS AND EXPERIENCE DRIVER'S LICENSE * STATE TYPE LICENSE NO. EXPIRATION DATE Question A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YesNo Question B. Has a license, permit or privilage ever been suspended or revoked? YesNo IF THE ANSWER TO EITHER A OR B IS YES, PLEASE GIVE DETAILS * 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, LLC. Date* APPLICANT'S NAME * SOCIAL SECURITY NUMBER You are authorized to furnish stranco, LLC. 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, LLC. 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, LLC. 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, LLC. To photocopy this from as many times as required to obtain information from all previous employers. A copy of this form is valid. APPLICANT'S SIGNATURE * DATE *
