Date:

Name:

Home Phone:

Cell:

Address:

City:

State:

Zip:

SSN:

Position Applying For:

Referred By:

Previous Address 1:

City:

State:

Zip:

Previous Address 2:

City:

State:

Zip:

Emergency Contact:

1. Name:

Phone:

2. Name:

Phone:

Are you able to, with or without a reasonable accommodation, lift 50 Lbs. or more, repetitively?

Have you ever worked for this company before?
if yes, Where?

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

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

C. Are you legally able to work within the United States?

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

EXPERIENCE AND QUALIFICATIONS

Driver
Licenses
STATE LICENSE NO. TYPE EXPIRATION Date

DRIVING EXPERIENCE

Class of Equipment Type of Equip.
Van, tank, flat, etc
From date To date Total years, months, etc.

Straight Truck

Tractor & semi-trailer

Tractor & two trailers

Other

Dozer

Motor grader

Scraper

Backhoe

Trackhoe

Mechanic

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (attach sheet if more space is needed)

Dates Nature of accident Fatalities Injuries

Last accident

Next previous
Next previous

Traffic convictions and forfeitures for the past 3 years

Location Date Charge Penalty

Note: DOT Requires that Employment for at least 3 years and /or Commercial Driving Experience for the past 10 years be shown.

Previous Employer 1:

Name:

Contact:

Address:

Phone:

Position:

From:

To:

Reason for leaving:

Previous Employer 2:

Name:

Contact:

Address:

Phone:

Position:

From:

To:

Reason for leaving:

Previous Employer 3:

Name:

Contact:

Address:

Phone:

Position:

From:

To:

Reason for leaving:

Previous Employer 4:

Name:

Contact:

Address:

Phone:

Position:

From:

To:

Reason for leaving:

Previous Employer 5:

Name:

Contact:

Address:

Phone:

Position:

From:

To:

Reason for leaving:

References: (non related)

1. Name Address Phone

2. Name Address Phone

3. Name Address Phone

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

In connection with Anadarko Dozer and Trucking, LLC considering me for employment, continued employment promotion or reassignment, I authorize AD&T, LLC and/or its agent to obtain a consumer report which may include information on my character, general reputation, personal characteristics, and mode of living from public record sources or through personal interviews with previous employers or associates. Public record check may include but not limited to a criminal or felony background check and sex offender’s registry check. I understand that a consumer reporting agency investigation may include obtaining a motor vehicle license and understand that we will conform to the Driver Privacy Protection Act. The applicant is required for the motor vehicle to provide a consent form and a photo I.D. before obtaining the record. Our company will retain the consent form and the results for a period of 5 years.

I authorize, without reservation, any person or entity contacted by Anadarko Dozer & Trucking, LLC or its agent to furnish the above-stated information and I release any such person or entity from any and all liability for furnishing such information. I further release Anadarko Dozer & Trucking, LLC., its affiliate companies, their officers, employees and agents, and specifically, Anadarko Dozer & Trucking, LLC, their affiliated companies, their officers, employees and agents from any liability and responsibility arising from the preparation of said report. I understand that false or misleading statements or information made on this authorization, or made during the employment process, will disqualify me from consideration for employment or result in immediate discharge if employed.

You have the right, upon written request, to receive a written description of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act.

"I swear and affirm that everything I this application is true and correct. I understand that Anadarko Dozer & Trucking, LLC, reserves the right to refuse to hire me or to take disciplinary action up to and including discharge if it discovers that I have falsified any of the information in this application. Further, I consent to the background checks described in this application."

I HEREBY ACKNOWLEDGE RECEIPT:

Name: Date:

Signature

___________________________________

NOTE: a motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations