MRC Driver application

MRC Driver application
Michiana Recycling and Disposal
Name *

First Name Last Name
E-mail *
ALL EMPLOYEES ARE REQUIRED TO PASS A DRUG SCREEN AND POST JOB OFFER EMPLOYMENT PHYSICAL PRIOR TO HIRING.
ALL QUALIFIED APPLICANTS WILL RECEIVE EQUAL CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE OR HANDICAP THAT IS UNRELATED TO THEIR ABILITY TO PERFORM THE JOB THEY ARE APPLYING FOR.
Date *

- Month - Day Year
Position applying for: *
How did you hear about the position? *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number *

- Area Code Phone Number
Mobile Phone Number *

- Area Code Phone Number
If less than 3 years at your current address... List all addresses for the past 3 years with dates: *
Are you 18 or over? (this question is to determine if you of legal age for employment}: *

Yes No
Are you authorized to work in the U.S.? *

Yes No
Emergency contact Name *

First Name Last Name
Emergency contact Phone Number *

- Area Code Phone Number
Emergency contact relationship: *
Do you have any friends or relatives who now or in the past have been employed by the company? if yes list Names and Dates: *
Have you been convicted of a felony? *

Yes No
If yes, Why? *
I can preform the essential function of the job in which I am applying for with or without accommodation: *

Yes No
If no please explain *
List all educational work experience which you feel qualify you for this position: *
List any special courses of training which you have completed that will help you as a driver: *
List any safe driving awards you have earned: *
School Name: *
Years Attended: *
Did you graduate? *

Yes No
City of School: *
What hobbies/past history and or experiences make you think you would be a good fit for Michiana recycling? *
DRIVER EXPERIENCE AND QUALIFICATION

ANSWER THE QUESTIONS IN THE FOLLOWING SECTION ONLY IF APPLYING FOR A DRIVER POSITION:
Date of Birth: (The U.S. Department of Transportation requires that driver applications state their date of birth (section (b) (2)). *

- Month - Day Year
Current Driver License Number? *
Drivers Licenses held in the past 3 years must be shown: List State, License No. Class Endorsements, Expiration Date. *
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? *

Yes No
B. Has any license, permit or privilege ever been suspended or revoked? *

Yes No
If you answered yes to A, B, please give a statement of the details: *
EMPLOYMENT RECORD (ALL INFORMATION MUST BE COMPLETE) TO BE CONSIDERED FOR EMPLOYMENT.

Please provide all previous work history. Start with the last or current held, and work back.
Are you currently employed? *

Yes No
Current / Previous employer: *

Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number: *

- Area Code Phone Number
Job Title: *
Supervisor Name: *

First Name Last Name
Date From: *

- Month - Day Year
Date To: *

- Month - Day Year
Pay rate per hour: *
Insurance Provided: *

Yes No
How much do you pay for insurance
Reason for Leaving: *
May we contact all current and previous employers? *
Previous employer 1. company name: *

Previous employer 1 address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Previous employer 1. Phone Number: *

- Area Code Phone Number
Previous employer 1 Job Title: *
Previous employer 1 date from: *

- Month - Day Year
Previous employer 1 date to: *

- Month - Day Year
Previous employer 1 pay rate per hour: *
Previous employer 1 reason for leaving: *
Previous employer 1 Supervisors Name: *

First Name Last Name
Previous employer 2 company name: *

Previous employer 2 address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Previous employer 2 phone number: *

- Area Code Phone Number
Previous employer 2 Job title: *
Previous employer 2 date from: *

- Month - Day Year
Previous employer 2 date to: *

- Month - Day Year
Previous employer 2 Pay rate per hour: *
Previous employer 2 Reason for leaving: *
Previous employer 2 Supervisors name: *

First Name Last Name
Previous employer 3 company name: *

Previous employer 3 address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Previous employer 3 date from: *

- Month - Day Year
Previous employer 3 date to: *

- Month - Day Year
Previous employer 3 Phone: *

- Area Code Phone Number
Previous employer 3 pay rate per hour: *
Previous employer 3 reason for leaving: *
Previous employer 3 supervisors name: *

First Name Last Name
Previous employer 4 company name: *

Previous employer 4 address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Previous employer 4 date from: *

- Month - Day Year
Previous employer 4 date to: *

- Month - Day Year
Previous employer 4 Phone Number: *

- Area Code Phone Number
Previous employer 4 Reason for leaving: *
Previous employer 5 company name: *

Previous employer 5 address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Previous employer 5 date from: *

- Month - Day Year
Previous employer 5 date to: *

- Month - Day Year
Previous employer 5 Phone number: *

- Area Code Phone Number
Previous employer 5 reason for leaving: *
Driving Experience
Straight Truck: *

Yes No
Other: *
Type of Equipment (van, tank, flat, etc.) *
Date From: *

- Month - Day Year
Date To: *

- Month - Day Year
Approximate Miles Driven: *
Tractor and Semi-Trailer: *

Yes No
Type of Equipment: *
Date From: *

- Month - Day Year
Date To: *

- Month - Day Year
Approximate Miles: *
Twin Trailers - LCV's: *

Yes No
Type of Equipment: *
Date From: *

- Month - Day Year
Date To: *

- Month - Day Year
Approximate Miles: *
Type of Equipment: *
Date From: *

- Month - Day Year
Date To: *

- Month - Day Year
List the states operated in during the last five (5) years: *
Accident Review for the past three (3) years
Date *

- Month - Day Year
Nature of accident: *
Fatalities: *

Yes No
Injuries: *

Yes No
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST THREE (3) YEARS (other than parking violations)
Location: *
Date *

- Month - Day Year
Violation / Charge: *
Penalty: *
Have you ever been convicted of driving while under the influence of Alcohol or Drugs? *

Yes No
When: *
Where: *
Signature

Clear
Should be Empty:

MRC Driver application

Michiana Recycling and Disposal

DRIVER EXPERIENCE AND QUALIFICATION

EMPLOYMENT RECORD (ALL INFORMATION MUST BE COMPLETE) TO BE CONSIDERED FOR EMPLOYMENT.

Driving Experience

Accident Review for the past three (3) years

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST THREE (3) YEARS (other than parking violations)