Employment Application – U.S. Hydro X

Personal Information

Date *

Date is required.

First Name *

First name is required.

Middle Name

Last Name *

Last name is required.

Phone *

A valid phone number is required.

Email Address *

A valid email is required.

Current Address *

Street

Street address is required.

City

City is required.

State

State is required.

ZIP

ZIP is required.

Years at Address

If at current address less than 3 years, list previous address(es):

Previous Address 1

Previous Address 2

Position Applying For *

Position is required.

Rate of Pay Expected

Who Referred You?

When Available for Work?

Names of Any Relatives Employed by This Company

Education – Training – Awards

Highest Grade / Education Completed

Last School Attended (Name & City)

Special Courses or Training That Will Help You as a Driver

Driving Awards Held and From Which Company

General

Have you ever been denied a bond?

No Yes

If yes, when?

Have you ever been convicted of a crime other than traffic violations?

No Yes

If yes, explain:

Employment History – Most Recent First (Last 10 Years)

Do not leave gaps between employment dates. If unemployed, state so and give dates. Include military experience. Attach a separate sheet for more than 5 employers.

Employer 1 (Most Recent)

Company Name

Supervisor's Name

Address

Phone

Position Held

From (MM/YYYY)

To (MM/YYYY)

Pay

FMCSR Safety Regulations?

Yes No

DOT Drug & Alcohol Testing (49 CFR Part 40)?

Yes No

Reason for Leaving

Employer 2

Company Name

Supervisor's Name

Address

Phone

Position Held

From (MM/YYYY)

To (MM/YYYY)

Pay

FMCSR Safety Regulations?

Yes No

DOT Drug & Alcohol Testing (49 CFR Part 40)?

Yes No

Reason for Leaving

Employer 3

Company Name

Supervisor's Name

Address

Phone

Position Held

From (MM/YYYY)

To (MM/YYYY)

Pay

FMCSR Safety Regulations?

Yes No

DOT Drug & Alcohol Testing (49 CFR Part 40)?

Yes No

Reason for Leaving

Employer 4

Company Name

Supervisor's Name

Address

Phone

Position Held

From (MM/YYYY)

To (MM/YYYY)

Pay

FMCSR Safety Regulations?

Yes No

DOT Drug & Alcohol Testing (49 CFR Part 40)?

Yes No

Reason for Leaving

Employer 5

Company Name

Supervisor's Name

Address

Phone

Position Held

From (MM/YYYY)

To (MM/YYYY)

Pay

FMCSR Safety Regulations?

Yes No

DOT Drug & Alcohol Testing (49 CFR Part 40)?

Yes No

Reason for Leaving

Driver's License Information

License # *

License # is required.

State *

State is required.

Expiration Date *

Expiration date is required.

Date of Birth *

Date of birth is required.

CDL Class

Restrictions

Endorsements

SSN (last 4 digits only)

Driving Experience

Type of Equipment	Years of Experience	Manual or Automatic?
Flatbeds
Straight Trucks
Tractors
Semitrailers
Doubles (Pups)

Accidents – Previous 3 Years

List all accidents in the previous 3 years. Leave blank if none.

Date

Nature of Accident

Injuries

Fatalities

Date

Nature of Accident

Injuries

Fatalities

Date

Nature of Accident

Injuries

Fatalities

Traffic Violations – Previous 3 Years (Excluding Parking)

List all convictions or bond forfeitures in the previous 3 years, excluding parking violations. Leave blank if none.

Date

Offense

Location

Date

Offense

Location

Date

Offense

Location

License Denial / Revocation / Suspension

Have you ever had a denial, revocation, or suspension of any license, permit, or privilege to operate a motor vehicle?

No Yes

If yes, explain:

Certification & Signature

This Company does not discriminate on the basis of race, color, religion, creed, national origin, sex, ancestry, or age.

I certify that I have read and understand all of this employment application. The employer or his agents may investigate my background, and I release all persons named herein from liability for any damages on account of furnishing such information. I understand employment may be conditioned on a physical examination and drug test.

I further certify that all entries on this application are true and complete to the best of my knowledge. Misrepresentation or omission of facts may result in rejection or dismissal. If hired, I agree to abide by all rules and policies of the employer.

NOTE: You have the right to review information obtained from previous employers and submit corrections within 30 days.

Date *

Date is required.

Signature * – Sign using your mouse or finger

Sign here

Signature is required.