EXPERIENCE LEVEL

Type: VAN FLATBEDDUMP Years:  Approx. # of Miles: 

Have you ever had your license suspended or revoked? YES NO

Have you  been convicted of DUI or DWI in past 5 yrs    YES NO

Have you  been involved in an accident? YES NO  When: 

Have you  been involved in an accident where someone other than your self was seriously injured or killed? YES NO

Have you ever been convicted of a crime? YES NO

Were you in the Armed Forces? YES NO

Have you abandoned an emperors truck? YES NO

Have you been fired from a job because of safety or log violations? YES NO

Are you able with or without reasonable accommodations to perform
the functions of the job for which you have applied? YES NO

Have you ever failed or refused a drug or alcohol test? YES NO

Do your have a TWIC card? YES NO

If answer to ANY question is yes, state details, circumstances, and date:

EQUIPMENT PROFILE:

EMPLOYMENT/LEASE HISTORY

Current Or Last Employer/Leasor:
Company Name: 
Address: 
City: 
State: Zip Code: 
Dates of Employment: From: To: 
Phone Number: 
Supervisor: 
Reason for leaving: 

EMPLOYMENT/LEASE HISTORY
Previous Employer/Leasor:
Company Name: 
Address: 
City: 
State: Zip Code: 
Dates of Employment: From: To: 
Phone Number: 
Supervisor: 
Reason for leaving: 

EMPLOYMENT/LEASE HISTORY
Previous Employer/Leasor:
Company Name: 
Address: 
City: 
State: Zip Code: 
Dates of Employment: From: To: 
Phone Number: 
Supervisor: 
Reason for leaving: 

EMPLOYMENT/LEASE HISTORY
Previous Employer/Leasor:
Company Name: 
Address: 
City: 
State: Zip Code: 
Dates of Employment: From: To: 
Phone Number: 
Supervisor: 
Reason for leaving: 

Authorization

SHELTON TRUCKING SERVICE (APPLICANTS NOTIFICATION AND RELEASE) 1. AUTHORIZATION FOR EMPLOYMENT REFERENCES I hereby authorize any and all current and previous employer's to furnish to Shelton Trucking Services with all information regarding my services, character, and conduct while in their employ. Furthermore, I hereby release said current and previous employers from any liability which may result from providing such information. 2. INFORMATION REQUEST FROM HIRERIGHT In connection with my application for employment with Shelton Trucking Services, I understand that a consumer report which may contain public record information is being requested from Hireright. This report may contain the following type of information: names and dates of previous employers, reasons for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, worker's compensation, bankruptcy, etc. from state, federal, and other agencies which may contain such records as well as information from Hireright concerning: l) state provided records 2) previous driving records requests made by others from such state agencies; 3 claims involving me in the files of insurance companies. I hereby authorize, without reservation, any party or agency contacted by Hireright to furnish the above mentioned information. 3. DRUG TEST HISTORY RELEASE I hereby give my voluntary consent for any previous employer, Hireright or Medical Review Officer or any of their respective agents and employees to release and disclose the following information concerning any of my past controlled substance tests. I also authorize, Shelton Trucking Services to obtain the following information from past controlled substance tests: 1) The types of controlled substances for which I submitted a urine specimen. 2) The date and location of such collection. 3) The identity of person or entity: (a) Performing the collection. (b) Analyzing the specimens. (c) Serving as medical review officer. 4) Whether the test finding was POSITIVE or NEGATIVE and if POSITIVE, the controlled substance identified in any positive test. I HEREBY KNOWINGLY AND VOLUNTARY RELEASE ALL PERSONS AND ENTITIES FROM ANY AND ALL CLAIMS OR LIABILITIES FOR RELEASING INFORMATION DESCRIBED IN THIS FORM TO SHELTON TRUCKING SERVICES. I CERTIFY THAT I HAVE READ, UNDERSTAND AND AGREE TO ALL PROVISIONS OF THIS FORM.

In lieu of signature for authorization please enter your Birth Date.