JMW Transfer, Inc.

Applicant Name:

Date of Application:

Email Address:

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

Position(s) Applied For:

Middle Initial:

List your addresses of residency for the past 3 years.

Current Address:

Current Address

Address:

City:

State:

Zip Code:

How Long? (yr./mo.):

Select:

Previous Addresses:

Do you have the legal right to work in the United States?

Phone Number:

Social Security No.

Date of Birth:

Can you provide proof of age?

Have you worked here before?

Are you currently employed?

How long since last employment?

Who referred you?

Rate of Pay Expected:

Have you ever been bonded?

Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]?

If yes, explain if you wish.

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle.

(NOTE: List employers in reverse order starting with the most recent.)

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

No employment history:

Employment History 1

Employer Name:

Address:

City:

State:

Zip:

Contact Person:

Phone Number:

Were you subject to the FMCSRs** while employed?

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

From:

To:

Position Held:

Salary/Wage:

Reason for Leaving:

**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle:

(1) weighs or has a GVWR of 10,001 pounds or more,

(2) is designed or used to transport more than 8 passengers (including the driver), OR

(3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Record any accidents for at least the last 3 years. If none, check the checkbox below.

No accident records:

Accident Record 1

Date:

Nature of Accident (head-on, rear-end, upset, etc.):

Any Fatalities?

Any Injuries?

Any hazardous material spill?

List traffic convictions and forfeitures for the past 3 years (other than parking violations). If none, check the checkbox below.

No traffic convictions:

Traffic Conviction 1

Location:

Date:

Charge:

Penalty:

List driver licenses or permits held in the past 3 years. If none, check the checkbox below.

No license information:

License 1

State:

License No. (include dashes):

Class:

Endorsement(s):

Expiration Date:

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

B. Has any license, permit or privilege ever been suspended or revoked?

If the answer to either A or B is yes, give details:

Check the boxes for any that you have experience with.

Straight Truck:

Tractor and Semi-Trailer:

Tractor - Two Trailers:

Tractor - Three Trailers:

Motor Coach (More than 8 passengers):

Motor Coach (More than 15 passengers):

Other (optional):

Class:

Type:

To:

From:

Approximate # of Miles Total:

List States Operated In For Last 5 Years (NONE if none):

Show Special Courses Or Training That Will help You As a Driver (NONE if none):

Which Safe Driving Awards Do You Hold And From Whom? (NONE if none):

Show any trucking, transportation, or other experience that may help in your work for this company:

List courses and training other than shown elsewhere in this application:

List special equipment or technical materials you can work with (other than those already shown):

Select highest grade completed:

Last School Attended:

Name of School:

City:

State:

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been-extended.) I hereby release employers, schools, health care 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 the Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

Review information provided by previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

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.

Electronic Signature:

Date:

Job Application

Section 1: Name and Date

Section 2: Applicant Information

Current Address

Section 3: Employment History

Employment History 1

Section 4: Accident Record

Accident Record 1

Section 5: Traffic Convictions

Traffic Conviction 1

Section 6: License Information

License 1

Section 7: Driving Experience

Section 8: Qualifications and Education

Section 9: Applicant Signature