DRIVER EMPLOYMENT APPLICATION

DRIVER EMPLOYMENT APPLICATION

An Equal Opportunity Employer
COMPLETE IN FULL OR IT WILL NOT BE CONSIDERED.
Employer Information
Employer: Mason's Propane Service LLC

317 W. King St.

East Berlin, Pennsylvania 17316

(717) 259-0624
It is the policy of Mason's Propane Service LLC to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.
Applicant Information
NAME*

First NameLast Name
PHONE*
EMAIL*
example@example.com
DATE OF BIRTH *

MonthDayYear
Date
SOCIAL SECURITY #*
###/##/####
DATE OF APPLICATION*

MonthDayYear
Date
POSITION APPLIED FOR*
DATE AVAILABLE FOR WORK*

MonthDayYear
Date
PREVIOUS THREE YEARS RESIDENCY
CURRENT*

Street Address

Street Address Line 2

CityState

Zip Code
# OF YEARS AT ADDRESS*
ADD ANOTHER PREVIOUS ADDRESS?*

YESNO
PREVIOUS*

Street Address

Street Address Line 2

CityState

Zip Code
# OF YEARS AT ADDRESS*
ADD ANOTHER PREVIOUS ADDRESS?*

YESNO
PREVIOUS*

Street Address

Street Address Line 2

CityState

Zip Code
# OF YEARS AT ADDRESS*
ADD ANOTHER PREVIOUS ADDRESS?*

YESNO
PREVIOUS*

Street Address

Street Address Line 2

CityState

Zip Code
# OF YEARS AT ADDRESS*
ADD ANOTHER PREVIOUS ADDRESS?*

YESNO
PREVIOUS*

Street Address

Street Address Line 2

CityState

Zip Code
# OF YEARS AT ADDRESS*
ADD ANOTHER PREVIOUS ADDRESS?*

YESNO
PREVIOUS*

Street Address

Street Address Line 2

CityState

Zip Code
# OF YEARS AT ADDRESS*
ADD ANOTHER PREVIOUS ADDRESS?*

YESNO
PREVIOUS*

Street Address

Street Address Line 2

CityState

Zip Code
# OF YEARS AT ADDRESS*
ADD ANOTHER PREVIOUS ADDRESS?*

YESNO
PREVIOUS*

Street Address

Street Address Line 2

CityState

Zip Code
# OF YEARS AT ADDRESS*
ADD ANOTHER PREVIOUS ADDRESS?*

YESNO
PREVIOUS*

Street Address

Street Address Line 2

CityState

Zip Code
# OF YEARS AT ADDRESS*
LICENSE INFORMATION

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.
STATE & LICENSE #*
TYPE/CLASS*
ENDORSEMENTS*
EXPIRATION DATE*

MonthDayYear
Date
PREVIOUSLY HELD LICENSES
DO YOU HAVE ANY PREVIOUSLY HELD LICENSES?*

YESNO
STATE & LICENSE #*
TYPE/CLASS*
ENDORSEMENTS*
EXPIRATION DATE*

MonthDayYear
Date
DO YOU HAVE ANY PREVIOUSLY HELD LICENSES?*

YESNO
STATE & LICENSE #*
TYPE/CLASS*
ENDORSEMENTS*
EXPIRATION DATE*

MonthDayYear
Date
DRIVING EXPERIENCE

CLASS OF EQUIPMENT *

	TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	DATE FROM	DATE TO	APPROX # OF MILES (TOTAL)
STRAIGHT TRUCK
TRACTOR & SEMI-TRAILER
TRACTOR & 2 TRAILERS
TRACTOR & TANKER
OTHER

ACCIDENT RECORD FOR THE PAST 3 YEARS*

	DATES (List most recent first)	NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.)	# FATALITIES	# INJURIES	CHEMICAL SPILLS (Y/N)
MOST RECENT
PREVIOUS RECORD
PREVIOUS RECORD
PREVIOUS RECORD
PREVIOUS RECORD
PREVIOUS RECORD
PREVIOUS RECORD
PREVIOUS RECORD
PREVIOUS RECORD
PREVIOUS RECORD

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)*

	DATE CONVICTED (Month/Year)	VIOLATION	STATE OF VIOLATION	PENALTY (Forfeited bond, collateral and/or points)
TRAFFIC CONVICTION OR FORFEITURE
TRAFFIC CONVICTION OR FORFEITURE
TRAFFIC CONVICTION OR FORFEITURE
TRAFFIC CONVICTION OR FORFEITURE
TRAFFIC CONVICTION OR FORFEITURE
TRAFFIC CONVICTION OR FORFEITURE
TRAFFIC CONVICTION OR FORFEITURE
TRAFFIC CONVICTION OR FORFEITURE
TRAFFIC CONVICTION OR FORFEITURE
TRAFFIC CONVICTION OR FORFEITURE

Have you ever been denied a license, permit, or privilege to operate a motor vehicle? If yes, explain *

YESNO
Has any license, permit, or privilege ever been suspended or revoked? If yes, explain *

YESNO
If you answered yes to either question, please explain.
The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.

Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state,zip; and complete all other information.
Do you have previous employment?*

YesNo
CURRENT (MOST RECENT) EMPLOYER NAME *
PHONE NUMBER*
ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
POSITION HELD*
FROM MO/YR*

MonthDayYear
Date
TO MO/YR*

MonthDayYear
Date
REASON FOR LEAVING *
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*

YESNO
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing asrequired by 49 CFR, part 40?*

YESNO
Do you have another employer to list?*

YesNo
SECOND (MOST RECENT) EMPLOYER NAME *
PHONE NUMBER*
ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
POSITION HELD*
FROM MO/YR*

MonthDayYear
Date
TO MO/YR*

MonthDayYear
Date
REASON FOR LEAVING
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*

YESNO
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing asrequired by 49 CFR, part 40?*

YESNO
Do you have another employer to list?*

YesNo
THIRD (MOST RECENT) EMPLOYER NAME *
PHONE NUMBER*
ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
POSITION HELD*
FROM MO/YR*

MonthDayYear
Date
TO MO/YR*

MonthDayYear
Date
REASON FOR LEAVING *
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*

YESNO
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing asrequired by 49 CFR, part 40?*

YESNO

EDUCATION*

	NAME & LOCATION	COURSE OF STUDY	YEARS COMPLETED	GRADUATE Y/ N	DETAILS
High School
College
Other

Please list any other qualificationsthat you have and which you believe should be considered.*
TO BE READ AND SIGNED BY APPLICANT

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to:

• Review information provided by current/previous employers;

• Have errors in the information corrected by previous employers, and for those previous employers to resend 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.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.
I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS. *

Yes, I agree and understand these terms.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

DRIVER EMPLOYMENT APPLICATION

Employer Information

Applicant Information

LICENSE INFORMATION