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All of the information
requested below is required. Please be as complete as possible in your
responses. If you would rather not send personal information over the
internet, this form may be printed, filled in by hand, and faxed or mailed to
us.
A. N. Webber Inc.
PO Box 95
Chebanse, IL 60922
Fax: 815-939-0645
Date:
Name: First
Middle
Last
Address
Home
Telephone:
City : State : Zip :
Cell:
Date Of Birth:
Social Security Number:
-
-
Have you ever been
convicted of a Felony?
YES NO
Conviction of a crime is not an automatic bar to employment - all
circumstances will be considered. If yes, please fully explain:
Have you ever worked for this company
before? YES NO
Who referred you?
If your above address is less than 3 years continue listing
them below to cover the previous 3 year period:
Street
Dates:
To
City : State : Zip :
Street
Dates:
To
City : State : Zip :
Street
Dates:
To
City : State : Zip :
Driver's License Information:
all
licenses held, last three years
State: Number:
Expiration:
Endorsements:
State: Number:
Expiration:
State: Number:
Expiration:
Experience:
Type of vehicle driven
From
To
Approx. mileage driven
Type of vehicle driven
From
To
Approx. mileage driven
Type of vehicle driven
From
To
Approx. mileage driven
All Accidents, last 3 years: (If none, write NONE.)
Date
Describe
Fatalities
Injuries
Date
Describe
Fatalities
Injuries
Date
Describe
Fatalities
Injuries
List all Traffic Violations, Convictions, last 3 years: (If none,
write NONE.)
Date
Violation
State
Commercial Vehicle: YES NO
Date
Violation
State
Commercial Vehicle: YES NO
Date
Violation
State
Commercial Vehicle: YES NO
Date
Violation
State
Commercial Vehicle: YES NO
Date
Violation
State
Commercial Vehicle: YES NO
Date
Violation
State
Commercial Vehicle: YES NO
Date
Violation
State
Commercial Vehicle: YES NO
Date
Violation
State
Commercial Vehicle: YES NO
Have you ever had any driver license denied, suspended, revoked,
or canceled by any issuing state agency?
YES NO
If yes, Provide state and Explanation:
Employment History Last 10 Years - account
for gaps: (if owner/operator, list carriers leased to)
Current Or Last Employer:
Dates:
To
Address:
Supervisor:
City:
State:
Zip:
Telephone:
Fax:
Were you subject to the Federal Motor Carrier Safety Regulations during this
period? YES NO
Were you subject to 49 CFR part 40 controlled substance
and alcohol testing during this period? YES NO
Reason for Leaving:
Employer:
Dates:
To
Address:
Supervisor:
City:
State:
Zip:
Telephone:
Fax:
Were you subject to the Federal Motor
Carrier Safety Regulations during this period? YES NO
Were you subject to 49 CFR part 40 controlled
substance and alcohol testing during this period? YES NO
Reason for Leaving:
Employer:
Dates:
To
Address:
Supervisor:
City:
State:
Zip:
Telephone:
Fax:
Were you subject to the Federal Motor
Carrier Safety Regulations during this period? YES NO
Were you subject to 49 CFR part 40 controlled
substance and alcohol testing during this period? YES NO
Reason for Leaving:
Employer:
Dates:
To
Address:
Supervisor:
City:
State:
Zip:
Telephone:
Fax:
Were you subject to the Federal Motor
Carrier Safety Regulations during this period? YES NO
Were you subject to 49 CFR part 40 controlled
substance and alcohol testing during this period? YES NO
Reason for Leaving:
Employer:
Dates:
To
Address:
Supervisor:
City:
State:
Zip:
Telephone:
Fax:
Were you subject to the Federal Motor
Carrier Safety Regulations during this period? YES NO
Were you subject to 49 CFR part 40 controlled
substance and alcohol testing during this period? YES NO
Reason for Leaving:
Employer:
Dates:
To
Address:
Supervisor:
City:
State:
Zip:
Telephone:
Fax:
Were you subject to the Federal Motor
Carrier Safety Regulations during this period? YES NO
Were you subject to 49 CFR part 40 controlled
substance and alcohol testing during this period? YES NO
Reason for Leaving:
Employer:
Dates:
To
Address:
Supervisor:
City:
State:
Zip:
Telephone:
Fax:
Were you subject to the Federal Motor
Carrier Safety Regulations during this period? YES NO
Were you subject to 49 CFR part 40 controlled
substance and alcohol testing during this period? YES NO
Reason for Leaving:
Employer:
Dates:
To
Address:
Supervisor:
City:
State:
Zip:
Telephone:
Fax:
Were you subject to the Federal Motor
Carrier Safety Regulations during this period? YES NO
Were you subject to 49 CFR part 40 controlled
substance and alcohol testing during this period? YES NO
Reason for Leaving:
Employer:
Dates:
To
Address:
Supervisor:
City:
State:
Zip:
Telephone:
Fax:
Were you subject to the Federal Motor
Carrier Safety Regulations during this period? YES NO
Were you subject to 49 CFR part 40 controlled
substance and alcohol testing during this period? YES NO
Reason for Leaving:
Have you ever tested positive, or refused to test, on any
pre-employment drug or alcohol test administered by an employer to which
you applied for, during the past three years?
YES NO
If YES: Have you successfully competed the return-to-duty process? YES NO
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