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Skillett & Sons, Inc.Online Driver's Application for Employment P.O. Box 196 Rush Center, KS 67575
Name Driver's License Number State Phone Number Date of Birth (Required for Commercial Drivers) Can you provide proof of age? Yes No Position(s) Applied for
By checking this box I authorize Skillett and Sons, Inc. to make such investigations 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 the information I provide regarding current and/or previous employers 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 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 employer(s) and I cannot agree on the accuracy of the information.
Current Address City State Zip How Long Current Phone Emergency Number Previous Address City State Zip How Long Previous Address City State Zip How Long
Emergency Contact Relationship
Have you worked for this company before? Yes No If yes, where? Dates: From to Rate of Pay Position Reason for Leaving
Are you now employed? Yes No If not, how long since leaving last employment?
Who referred you? Rate of Pay Expected
Have you ever been bonded? (Answer only if a job requirement.) Yes No Name of Bonding Company
Have you ever been convicted of a felony? Yes No If yes, explain. 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? Yes No If yes, explain if you wish.
EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employees during the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. A full 10 years is required. (NOTE: List employers in reverse order starting with the most recent.)
Employer Information: Include Name, Address, City, State, Zip, Contact Person & Phone Number, Dates Employed, Position Held, Salary/Wage, Reason for Leaving Where you subject to the FMCSR† 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 49 CFR Part 40? Yes No
ACCIDENT RECORD for the previous 3 years. If none, check this box. Last Accident: Include Date, Nature of Accident (head-on, rear-end, upset, etc.), Fatalities, Injuries, Hazardous Material Spill.
Next Previous Accident: Include Date, Nature of Accident (head-on, rear-end, upset, etc.), Fatalities, Injuries, Hazardous Material Spill.
TRAFFIC CONVICTIONS & FORFEITURES for the past 3 years (other than parking violations). If none, check this box.
Include the Location, Date, Charge and Penalty.
DRIVER QUALIFICATIONS List all driver licenses or permits held in the past 3 years.
Include State of Issuance, License Number, License Type and Expiration Date.
Have you even been denied a license, permit or privilege to operate a motor vehicle? Yes No Has any license, permit or privilege ever been suspended or revoked? Yes No If answer to either of the above two questions is Yes, explain below.
DRIVER EXPERIENCE
Class of Equipment — Check all that apply. Straight Truck Tractor & Semi-Trailer Tractor & Two Trailers Tractor & Three Trailers Motorcoach/School Bus - More than 8 passengers Motorcoach/School Bus - More than 15 passengers
Type of Equipment — Check all that apply. Van Tank Flat Dump Reefer
List states operated in for the last five years.
List special courses/training that will help you as a driver.
List safe driving awards and who issued them.
List any trucking, transportation and/or other experience that may help in your work with this company.
List any additional courses and/or training not already listed in this application.
List any additional equipment and/or technical materials you can work with not already listed in this application.
EDUCATION
What is the highest level of education you have completed? Grade School 1, 2, 3, 4, 5, 6, 7, or 8 High School 1, 2, 3, or 4 College 1, 2, 3, 4 or 5+ Last School Attended City/State
I certify that this 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.
Name of Applicant Date of Submission
*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designated to transport 15 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 10,0001 pounds or more, (2) is designated or used to transport 9 or more passengers, OR (3) if of any size and is used to transport hazardous materials requiring placarding.