R & C Stagelines, Inc
Mr. Darin Goldson, President
Employment Application
In compliance with Federal and State equal employment opportunity laws, applicants are considered for positions without discrimination on the basis of race, religion, sex, national origin, citizenship, age, disability, or any other consideration made unlawful by applicable
federal, state, or local laws. In order to be considered for employment, this application must be filled out COMPLETELY. Please write “N/A” if information is not applicable. Résumés, though welcome, should not be submitted in place of the information req. below.
Today’s Date _____/_____/_____ Position(s) applying for ______
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Last First Middle
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# Street City State Zip
3 Years Previous Residency
__/__/______
Dates: # Street City State Zip
__/__/______
Dates: # Street City State Zip
Phone Number ( ) - Best Time To Call ______
Social Security # Date Of Birth: ____/____/____
Date Available To Start: _____/_____/_____
Referred By: ______Rate of Pay Expected: $______
Emergency Contact Information
( ) -
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Name Phone Number Relationship
CDL Information
Do you have a CDL license? ______Class: ______
If so, License # ______State: ______Expiration Date: ______
Education
What is the highest level of education you have completed? ______
Experience
Total years of over the road experience: ______
Please know; a minimum of two years over the road driving experience is required.
Employment History (please provide employment history for the last 3 years)
If hired, U.S Citizenship or proof to work in the United States will be required.
Previous Employer Name______
Position Held______
Dates Employed _____/_____/_____ to _____/_____/_____
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# Street City State Zip
Supervisor ______Phone # ______Fax # ______
Reason for Leaving ______
Previous Employer Name______
Position Held______
Dates Employed _____/_____/_____ to _____/_____/_____
______
# Street City State Zip
Supervisor ______Phone # ______Fax # ______
Reason for Leaving ______
Previous Employer Name______
Position Held______
Dates Employed _____/_____/_____ to _____/_____/_____
______
# Street City State Zip
Supervisor ______Phone # ______Fax # ______
Reason for Leaving ______
Criminal Record
Have you ever been convicted of a felony? ______Date _____/_____/_____
Have you ever been convicted of or are there are pending charges for driving under the influence, possession, selling of alcohol, narcotics, amphetamines or derivatives thereof?
Date ____/____/____
Have you ever been denied a license or permit to operate a motor vehicle?______
Has your license, permit or privilege even been revoked? ______
Have you ever been refused any type of insurance or denied bonding? ______
Have you ever abandoned equipment in your possession? ______
Are you on probation or parole?
If you answered “yes” to any of the above, please explain below
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Accidents / Tickets
Please list ALL tickets and/or vehicle accidents including property damage for the past 5 years. Provide the dates, type, and injuries, and fatalities, amount of property damage and nature of the accident.
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To Be Read and Signed By Applicant
This certifies 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.
I authorize you to make such investigations and inquire 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 may result in discharge. I understand, also, that I am required to abide by all rules and regulations of R&C Stage lines.
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Date Applicant’s Signature
Process Record
THIS PAGE IS FOR OFFICE USE ONLY
Applicant Hired ______Rejected______
Date Employed ____/____/____ Point Employed ______
Department ______Classification ______
(if rejected, summary report of reason should be placed in file)
Superior / Good / Fair / Below Average / Poor / Written Record on file1.) Application
2.) Interview
3.) Past Employment
4.)Written Exam
5.) Road Test
6.) Criminal & Traffic Convictions
Signature Of Interviewing Officer ______Date: ____/____/____
Contingencies for Employment
I understand that if I am offered employment by R & C Stage lines, Inc. it is contingent upon the following:
1.) Clearance of required paper work by U.S. Postal Service.
2.) Clearance by R & C Stage lines, Inc. insurance carrier.
3.) Previous employer(s) drug and alcohol test information.
The above information will be kept confidential by R & C Stage lines, Inc.
Signature ______Date: ____/____/____
Special Employment Notice to Disabled Veterans, Vietnam Era Veterans, and Individuals with Physical or Mental Disabilities
Government contractors are subject to Section 402 of the Vietnam Era Veterans Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified disabled individuals.
If you are a disabled veteran, or have a physical or mental disability, you are invited to volunteer this information. The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job in a proper and safe manner. This information will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect any consideration you may receive for employment.
As employers, it is our responsibility to accept and follow government regulations and affirmative action responsibilities. To help us with federal, state equal employment opportunity record keeping, reporting and other legal requirements, please answer the questions below.
Date: ____/____/____
Job applied for: ______
Referred by: ______
Sex
Male: ______Female: ______
Race/Ethnic Group
White (Non-Hispanic) ______Black (Non-Hispanic) ______Hispanic ______
American Indian ______Asian Pacific ______Other ______
Are you a disabled Veteran? ______
Are you a Vietnam Veteran? ______
Do you have a disability? ______
Request for Previous Employment Information
I hereby authorize my previous and/or current employer to furnish R&C Stage Lines, Inc. the information requested below. I agree to release my previous and/or current employers from any liability that may arise from providing such information.
Please complete only the highlighted areas below.
Date ______Applicant’s Signature ______
Applicant’s Printed Name ______SSN ______
Witness ______Date ______
Prior Employer ______Address______
Phone ______Fax ______
NOTICE TO PREVIOUS EMPLOYER: PLEASE PROVIDE ALL INFORMATION REQUESTED BELOW IN ACCORDANCE WITH 49 CFR PART 391.23
The above applicant states they were employed with your company from ______to ______
Position ______Reason for leaving ______
Available for rehire ______
License ever revoked or suspended ____
Type of Tractor ______Type of Trailers ______
Did this employee have excessive tardiness or absents ______were they dependable ______
Did this employee have issues with meeting scheduled loading or unloading times ____
In Accordance with 49 CFR Part 40, Please answer the following
1. Has this person ever tested positive for a controlled substance? ______
2. Has this person ever had an alcohol test with results higher than 0.04? ______
3. Has this person ever refused a required test for drugs or alcohol? ______
4. Has this person ever violated any DOT drug or alcohol regulation?
5. Have you ever received information stating this person violated a DOT drug or alcohol regulation?
6. Was this employee ever injured? ______When? ______Type of Injury? ______
Previous Employer, if answered “yes” to any of the previous questions, please explain thoroughly. ______
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Accident/Incident Record, list all regardless of fault
DATE / VEHICLE / TYPE / FATALITIES / INJURIES / HAZMATRELEASE / CITY / ST / COST OF DAMAGE
Form Completed By ______Date ______
P.O. Box 26356 Albuquerque, NM 87125
Office (505)843–7461 Fax (505)843-7713 Email
www.RCStageLines.com