Employment Application

APPLICANT’S STATEMENT
I CERTIFY THAT I AM A GENUINE APPLICANT FOR EMPLOYMENT AND THIS APPLICATION IS BEING SUBMITTED SOLELY FOR THE PURPOSE OF SEEKING EMPLOYMENT WITH J. PETTIECORD, INC. AND FOR NO OTHER REASON.

I UNDERSTAND THAT THE INFORMATION IN THIS APPLICATION WILL BE USED AND THAT PRIOR EMPLOYERS WILL BE CONTACTED FOR PURPOSES OF INVESTIGATION AS REQUIRED BY SECTION 391-23 OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS.

THIS CERTIFIES THAT ALL ENTRIES ON THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND AND AGREE THAT IF I AM EMPLOYED, ANY FALSE STATEMENTS ON THE APPLICATION MAY BE GROUNDS FOR DISMISSAL.

I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY BE TERMINATED WITH OR WITHOUT CAUSE, AT ANY TIME AND WITHOUT PRIOR NOTICE. NOTHING HEREIN SHALL BE REGARDED AS A CONTRACT OF OR FOR EMPLOYMENT.

Position Applying For
Date of Birth
MM slash DD slash YYYY
Name
First Middle Last Maiden (IF ANY)
Address
Street Address City State ZIP Code
Phone
Email*
Resume
If you have a resume, you can upload the file here
Max. file size: 256 MB.
Referred By (if applicable)
Please list the name of the location or the person where you heard about us (ie: TV, Radio, Facebook, John Doe, Jane Doe, etc)
IF AT ABOVE ADDRESS LESS THAN THREE YEARS, LIST ALL RESIDENCES FOR PAST THREE YEARS
Residence #1
Street Address City State ZIP Code
Residence #2
Street Address City State ZIP Code
Residence #3
Street Address City State ZIP Code
Grammar School
School Name
Location
# of Years Attended
Did You Graduate?
- Yes
- No
Subjects Studied
High School
School Name
Location
# of Years Attended
Did You Graduate?
- Yes
- No
Subjects Studied
College
School Name
Location
# of Years Attended
Did You Graduate?
- Yes
- No
Subjects Studied
Trade, Business or Correspondence School
School Name
Location
# of Years Attended
Did You Graduate?
- Yes
- No
Subjects Studied
General
Subjects of special study/Research work OR Special Training/Skills
U.S. Military or Naval Service
Rank
Former Employers
List below last four employers, starting with most current
Employer 1
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Employer Name
Position
Address
Street Address City State ZIP Code
Salary
Reason For Leaving
Employer 2
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Employer Name
Position
Address
Street Address City State ZIP Code
Salary
Reason For Leaving
Employer 3
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Employer Name
Position
Address
Street Address City State ZIP Code
Salary
Reason For Leaving
Employer 4
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Employer Name
Position
Address
Street Address City State ZIP Code
Salary
Reason For Leaving
References
Give below the names of three persons not related to you, whom you have known at least one year.
Reference #1
Name
First Last
Address
Street Address City State ZIP Code
Business
Years Known
Phone
Reference #2
Name
First Last
Address
Street Address City State ZIP Code
Business
Years Known
Phone
Reference #3
Name
First Last
Address
Street Address City State ZIP Code
Business
Years Known
Phone
Equipment Operating History
Straight Truck
Type of Equipment (Vans, Tank, Flat, etc)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Approximite # of Miles (Total Miles)
Contractor & Semi-Trailer
Type of Equipment (Vans, Tank, Flat, etc)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Approximite # of Miles (Total Miles)
Twin Trailers
Type of Equipment (Vans, Tank, Flat, etc)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Approximite # of Miles (Total Miles)
Other
Type of Equipment (Vans, Tank, Flat, etc)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Approximite # of Miles (Total Miles)
Licenses
List licenses held in past three years
State
License #
License Type
Expiration Date
MM slash DD slash YYYY
State
License #
License Type
Expiration Date
MM slash DD slash YYYY
State
License #
License Type
Expiration Date
MM slash DD slash YYYY
List state(s) operated in for last five years
Accident Review for Past 3 Years
Most Recent Accident
Date
MM slash DD slash YYYY
Fatalities
- Yes
- No
Injuries
- Yes
- No
Nature of Accident
Head-on, rear-end, upset, etc
Next Previous Accident
Date
MM slash DD slash YYYY
Fatalities
- Yes
- No
Injuries
- Yes
- No
Nature of Accident
Head-on, rear-end, upset, etc
Next Previous Accident
Date
MM slash DD slash YYYY
Fatalities
- Yes
- No
Injuries
- Yes
- No
Nature of Accident
Head-on, rear-end, upset, etc
Traffic Convictions and Forfeitures for Past 3 Years
Location
Date
MM slash DD slash YYYY
Charges
Penalty
Location
Date
MM slash DD slash YYYY
Charges
Penalty
Location
Date
MM slash DD slash YYYY
Charges
Penalty
Have you ever 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 you answered Yes to either of the two questions above, you must provide an additional statement giving details below
AUTHORIZATION*
- I AGREE
I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU AND ANY AND ALL INFORMATION CONCERNING ANY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE THE FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION. I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE.
Signature*

IF AT ABOVE ADDRESS LESS THAN THREE YEARS, LIST ALL RESIDENCES FOR PAST THREE YEARS

Grammar School

High School

College

Trade, Business or Correspondence School

General

Former Employers

Employer 1

Employer 2

Employer 3

Employer 4

References

Reference #1

Reference #2

Reference #3

Equipment Operating History

Straight Truck

Contractor & Semi-Trailer

Twin Trailers

Other

Licenses

Accident Review for Past 3 Years

Most Recent Accident

Next Previous Accident

Next Previous Accident

Traffic Convictions and Forfeitures for Past 3 Years