Apply | Casella

Applicant Name*

Company*

Address*

City*

State*

Zip*

Email*

In compliance with Federal and State equal employment opportunity laws, qualified applicants яге 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.

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 employees) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). 1 understand 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 employees) and I cannot agree on the accuracy of the information.

Position(s) Applied for*

First Name*

Middle Name*

Last Name*

List your addresses of residency for the past 3 years.

Current Address

Street*

City*

State*

Zip Code*

Phone*

How Long? (yr./mo.)*

Previous Addresses

Street

City

State & Zip Code

How Long? (yr./mo.)

Street

City

State & Zip Code

How Long? (yr./mo.)

Street

City

State & Zip Code

How Long? (yr./mo.)

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

Yes
No

Date of Birth*

Can you provide proof of age?*

Yes
No

Have you worked for this company before?*

Yes
No

Where?*

Dates:

From*

To*

Rate of Pay*

Position*

Reason for leaving*

Are you now employed?*

Yes
No

How long since leaving last employment?

Who referred you?*

Rate of pay expected:*

Have you ever been bonded?

Name of bonding company

Have you ever been convicted of a felony?

Conviction of a crime is not an automatic bar to employment - all circumstances will be considered

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.*

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding 3 years. List complete mailing address, street number, city/state, and zip code. Applicants to drive a commercial motor vehicle* 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. Add another sheet as necessary.)

* Includes vehicles having a GV WR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers or any size vehicle used to transport hazardous materials in a quantity requiring placarding. 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 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Accident Record (for past 3 years or more, if none - write none)*

	Dates	Nature of accident	Fatalities	Injuries	Hazardous material spill

Traffic convictions and forfeitures for the past 3 years (if none- write none)

Location	Date	Charge	Penalty

Experience and qualifications - driver

List all driver licenses or permits hold in the past 3 years

Driver licenses

State	Licenses No.	Type	Expiration date

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

Yes
No

Have any license, permit or privilege ever been suspended or revoked?

Yes
No

Driving Experience

Class of Equipment

Class of Equipment	Equipment Type	Date From	Date To	Approx no. of miles (total)

Other Class of Equipment

List states operated in for the last five years

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

Which safe driving awards do you hold and from whom?

Experience and qualifications - other

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 the application

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

Education

Select highest grade completed

High school

College

Last school attended name

Last school attended city,state

Signature

Full Name*

Date*

By submitting this form and entering in my full name and the current date below, I certify that the 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.

Employment

Name*

Address*

City*

State*

Zip*

Contact Person*

Phone number*

Were you subject to the FMCSRs while employed?*

Yes
No

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

Yes
No

Date From*

Date to*

Position held

Salary/wage

Reason for leaving