Application

Ross Express Application for Employment

Name Date

First Middle Last

Telephone Number E-mail Address

*Current Address - If at the current residence less than three years, list below all residences for the past three years.

*Street City State Zip Code

*Street City State Zip Code

Position Applying for Temporary Part Time Full Time

Who referred you? Rate of pay expected?

Have you worked for this company before? Yes No From To

Where? Rate of Pay Position

Reason for leaving

Names of ay relatives employed by this company

Are you currently employed? Yes No If not, how long since leaving last employment?

EDUCATION

Check highest grade completed: 1234 56789101112 College: 1234

Last School Attended: Address:

GENERAL

Have you ever been bonded? Yes No Name of bonding company

Have you ever been convicted of a felony? Yes No If yes, please explain fully below. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.

Have you ever worked for this company under another name? Yes No

If so, under what name?

Driver Experience & Qualification

Answer the questions in this section only if applying for driver position

Date of Birth The U.S. Department of Transportation requires that driver applicants state their date of birth (391.21(b)(2))

Social Security No.

Licenses - Drivers Licenses held in the past 3 years must be shown

State License No. Class Endorsement(s) Expiration Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No

B. Has any of your licenses, permits or privilege ever been suspended or revoked? Yes No

C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes No

If you answered "yes" to A, B, C, include a statement giving details below:

Driving Experience

Class of Equipment
Type of Equipment (Van, Tank, Flat, etc.) Start Date End Date Approximate Total Miles

Straight Truck

Tractor and Semi-Trailer

Twin Trailers - LCV's

Other

List States operated in during last five years

List special courses or training that will help you as a driver

List driving awards held and who awards were presented by

Accident Review for past 3 years

Dates
Nature of accident (Head-On, Rear-End, Overturn, etc.) Fatalities Injuries

Last Accident

Next Previous

Next Previous

Traffic Convictions and Forfeitures for the past 3 years - Other than parking violations

Location Date Charge Penalty

Employment Record

The U.S. Department of Transportation requires that driver applications show all employment for the past three years. The must also show commercial driver employment for the seven years immediately preceding this three year period. 391.21(b)(10),(11)

Start with last or current position, including military experience, and work back.

Current Employer: Supervisor's Full Name:

Full Address: Zip: Phone:

Position Held: From: To: Salary:

Company: Supervisor's Full Name:

Full Address: Zip: Phone:

Position Held: From: To: Salary:

Company: Supervisor's Full Name:

Full Address: Zip: Phone:

Position Held: From: To: Salary:

Company: Supervisor's Full Name:

Full Address: Zip: Phone:

Position Held: From: To: Salary:

Maintenance Experience & Qualifications

List courses and training in maintenance work

Job Function

Shop Equipment

ASE Certification(s) (Specify)

List types of platform experience and number of years of each

List platform equipment you can operate (lift truck, etc.)

List courses or training in platform work

APPLICANT MUST READ AND ACKNOWLEDGE

I certify that I have read and understood all of this employment application. It is agreed and understood that the employer or his agent may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons named herein from all liability for any damages on account of furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the results of a physical examination and drug test.

I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include and investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of the employer.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Date I agree with the above: Yes No

Electronic Signature

_______________________________________________________________________________________________________

For mail applicants:

Date: _______________________ I agree with the above: Yes No