::: Application :::

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			Landfill Services
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			Salvage/Brick Sales

Apply

Name

I am appling for a position as

Non-CDL Driver

CDL Driver

Mechanic

Demolition Worker

Equipment Operator

CDL DRIVERS

If you are appling for a CDL Driver(Commerical Driver's License) position, please answer the following questions

How many years you had your CDL?

Enter your Date of birth

Enter your CDL license number,expiration,date and issuing state

Do you have roll-off truck experience?

Yes No

Do you have a clean MVR?

Yes No

Terms

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 otherrelated matters as may be necessary in arriving at an employment decision. Generally, inquiries regarding medical history will bemade only if and after a conditional offer of employment has been extended. I hereby release employers, schools, health careproviders and other persons from all liability in responding to inquiries and releasing information connected with my application.

In the event of employment, I understand that false or misleading information given in my application or interview may result indischarge. I also understand 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 employerscontacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23 (d) and (e).

I understand I have the right to review information provided by previous employers; to have errors in the information correctedby previous employers and for those previous employers to resend the corrected information to the prospective employer; andto have a rebuttal statement attached to allegedly erroneous information, if the previous employer(s) and I cannot agree on theaccuracy of the information.

I acknowledge that I completed this application, and that all the information contained in it is true and complete to the best of my knowledge.

Authorized Company Representative (Signature)

Date

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, marital status, veteran status, non-job related disability, or any other protected group status.

All applicants should complete this page PERSONAL INFORMATION

CONTACT INFORMATION

Last Name

First Name

Middle Name

Social Security #		Email
Phone No(Home)		Phone No(Cell)

List your addresses of residency for the last three years

Current Address

City, State, Zip

How long at this address? (years/months)

Previous Address

City, State, Zip

How long at this address? (years/months)

Previous Address

City, State, Zip

How long at this address? (years/months)

EMERGENCY CONTACT INFORMATION

Name
Phone Number		Relationship to Applicant

OTHER INFORMATION

OTHER INFORMATION

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

Yes

Have you ever been convicted of a felony? (this will not automatically bar you from employement)

Yes

If yes, please explain:

Are you at least 18 years of age?

Yes

Are you a veteran of the US military?

Yes

If you answered yes, are you currently on active duty or part of the military reserve?

Active Yes

All applicants should complete this page Training and Other Experience

Training and Other Experience

Have your worked for this company before?

Yes

When? From

To:

Position Held:

Reason for leaving:

Is there any reason that you might be unable to perform the job for which you have applied?

Yes

If yes, please explain:

Education

What is your level of education?

Less than High School

High School or GED

Some College

College Graduate

Last school attended

Date of last attendance

Experience: (Your employment history will be discussed in the next section)

Please list any experience that you feel might be helpful in your work for this company:

Please list any courses or training that you have had which might be helpful in your work for this company:

Please list any special equipment or technical materials that you can work with:

If there's any other information which you feel might be pertinent to our hiring decision, please record it here:

All applicants should complete this page Employment History

Employment History

Please record your current and former employers as follows: (see notes at bottom of this page)

Applicants to drive commercial motor vehicles (CDL drivers): Please provide your employment history for the last ten years;complete all information for each employer.

Applicants for non-CDL driver positions: Please provide the last three years of your employment history ; complete all sectionsfor each employer.

Applicants for non-driver positions: Please provide the last three years of your employment history, and fill out the "AllApplicants" section for each employer.

Please begin with the most recent employer, and list the remainder in reverse order (most recent to oldest); attach additionalsheets if necessary.

Name of employer	Contact
Address	Phone #
City, State Zip	Can we contact this person?	Yes NO
Date of employement: From	To
Position held	Salary/Wage
Reason for leaving

Were you subject to the FMCRS's while employed?	Yes	No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drugand alcohol testing requirements of 49 CFR Part 40?	Yes	No

Name of employer	Contact
Address	Phone #
City, State Zip	Can we contact this person?	Yes NO
Date of employement: From	To
Position held	Salary/Wage
Reason for leaving

Were you subject to the FMCRS's while employed?	Yes	No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drugand alcohol testing requirements of 49 CFR Part 40?	Yes	No

Note: The Federal Motor Carrier Safety Regulations (FMCSR's) apply to anyone operating a motor vehicle on a highway in interstate commerce to transportpassengers or property when the vehicle: has a GVWR of 10,001 pounds or more, is designed or used to transport 9 or more passengers, OR is of any size and isused to transport hazardous materials in a quantity requiring placarding.A commercial motor vehicle (as noted above) is any vehicle having a GVWR of 26,001 lbs or more, vehicles designed to transport 15 or more passengers, or anysize vehicle used to transport hazardous materials in a quantity requiring placarding.

Name of employer	Contact
Address	Phone #
City, State Zip	Can we contact this person?	Yes NO
Date of employement: From	To
Position held	Salary/Wage
Reason for leaving

Were you subject to the FMCRS's while employed?	Yes	No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drugand alcohol testing requirements of 49 CFR Part 40?	Yes	No

Name of employer	Contact
Address	Phone #
City, State Zip	Can we contact this person?	Yes NO
Date of employement: From	To
Position held	Salary/Wage
Reason for leaving

Were you subject to the FMCRS's while employed?	Yes	No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drugand alcohol testing requirements of 49 CFR Part 40?	Yes	No

Name of employer	Contact
Address	Phone #
City, State Zip	Can we contact this person?	Yes NO
Date of employement: From	To
Position held	Salary/Wage
Reason for leaving

Were you subject to the FMCRS's while employed?	Yes	No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drugand alcohol testing requirements of 49 CFR Part 40?	Yes	No

Only driver applicants should complete this page
Driving Experience and Safety Record

Driving Experience and Safety Record

Accident record: Please list any accidents in which you have been involved during the last three years.

Date
Nature of Accident(Head-On, Rear-End, Upset, etc.)
Fatalitites
Injuries
Penalty

Traffic convictions and Forfeitures: Please list any violations (other than parking tickets) durin the last three years

Date
Location
Type
Penalty

List all driver's licenses or permits held in the last three years

State
License #
Type
Expiration Date

Have you ever been denied a license, permit, or privelage to operate a motor vehicle?	Yes	No
Has any license, permit, or privelage that you held ever been suspended or revoked?	Yes	No

Has any license, permit, or privelage that you held ever been suspended or revoked?

Driving experience: Please indicate if you have had any experience driving the following types of equipment

Type
Circle Type of Equipment
Dates (from M/Y to M/Y)
Approximate # of Miles
Tractor and Semi-Trailer
(Van,Tank, Flat, Dump, Refer)
Tractor - Two Trailers
(Van,Tank, Flat, Dump, Refer)
Tractor - Three Trailers
(Van,Tank, Flat, Dump, Refer)
Motorcoach - School Bus
(Van,Tank, Flat, Dump, Refer)
Other
List states operated in during the last five years:
List any special courses or training that mighthelp you as a driver:
List any driver safety awards that you havereceived, and from whom they were received