Application Form – Graham International

COMPANY

STREET ADDRESS

CITY , AND STATE , ZIP CODE

FRIST NAME

MIDDLE NAME (IF HAVE)

Last Name

ADDRESS

HOW LONG

DATE OF BIRTH

SOCIAL SECURITY NO.

HIRE DATE

TELEPHONE NO.

E-MAIL ADDRESS

PREVIOUS THREE YEARS RESIDENCY

ADDRESS

YEAR

ADDRESS

YEAR

ADDRESS

YEAR

Section 383 21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do no have more than one motor vehicle license, the information for which is listed below.

STATE

LICENCE NO .

TYPE

DATE OF BIRTH

DRIVING EXPERIENCE

CLASS OF EQUIPMENT

From

TYPE OF EQUIPMENT (VAN, TANK, FLAT ETC)

TURCK

TRACTOR ANO SEMI -TRAILER

Others

ACCIDENT RECORD OF PAST 3 YEARS OR MORE

DATE

NATURE OF ACCIDENT (HEAD-ON, REAR-ENO, UPSET, ETC)

NUMBER FATALITIES

NUMBER INJURIES

CHEMICAL SPILLS

Yes No

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS

DATE CONVICTED (month/year)

VIOLATION

STATE OF VIOLATION LOCATION

PENALITY (forfeited bond, collator and/ or points)

A. Have you ever been denied for license, permit or privilege to operate a motor vehicle? If yes explain:

B. Has any license, permit or privilege ever been suspended or revoked? If yes explain:

EMPLOYMENT RECORD

Applicants that desire drive in intrastate / Interstate commerce must provide the following Information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the, initial three years (total often years employment record).

Must list the complete mailing address: street number and name, city, state and zip code.

LAST EMPLOYER:

NAME

ADDRESS

TELEPHONE NO.

POSITION HELD

FROM

SALARY

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED !NCLUDE DATES (MONTH/YEAR) AND REASON.

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode. subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes No

RESON FOR LEAVING

SECOND EMPLOYER:

NAME

ADDRESS

TELEPHONE NO.

POSITION FIELD

FROM

SELARY

RESON FOR LEAVE

ANY GAPS IN EMPLOYMENT AND / OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDED (MONTH/YEAR) AND REAON.

Where you subject to the Federal Motor Carrier Safety Requlations (FMCSRs)while employed by the previous employer

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode. subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes No

THIRD LAST EMPLOYER

Name

ADDRESS

POSITION FIELD

FROM

SELARY

REASON FOR LEAVE

ANY GAPS IN EMPLOYMENT AND / OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDED (MONTH/YEAR) AND REAON.

Where you subject to the Federal Motor Carrier Safety Requlations (FMCSRs)while employed by the previous employer

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode. subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes No

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make sure investigations and Inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arraying at an employment decision.(Generally, Inquiries regarding medical history will be made only if and after a conditional offer of employment have been exceeded.) 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 regulation of the Company. I understand that information I provide regarding current and/or previous employees 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 current/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 employee 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.
Review information provided by current/previous employers;

APPLICANT NAME

Date

This certifies that I completed this application and that all entrees on it and information in It are true and complete to the best of my knowledge. Note A motor earn may require an applicant to provide information in addition to the Information required by the Federal Motor Carrier Safety Regulations.

If you have file to upload

APPLICATION OF EMPLOYMENT

PREVIOUS THREE YEARS RESIDENCY

DRIVING EXPERIENCE

ACCIDENT RECORD OF PAST 3 YEARS OR MORE

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS

EMPLOYMENT RECORD

LAST EMPLOYER:

SECOND EMPLOYER:

ANY GAPS IN EMPLOYMENT AND / OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDED (MONTH/YEAR) AND REAON.

THIRD LAST EMPLOYER

ANY GAPS IN EMPLOYMENT AND / OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDED (MONTH/YEAR) AND REAON.

TO BE READ AND SIGNED BY APPLICANT

Review Information provided by current/previous employers;

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