NOTICE: Before an application is submitted, the motor carrier must inform the applicant that the information he/she provides in accordance with paragraph (b) (10) of this section may be used, and the applicant’s previous employers will be contacted, for the purpose of investigating the applicant’s safety performance history information as required by paragraphs (d) and (e) of 391.23.
Date Of Application (required)

Year

  
First Name (required)
Last Name (required)
Current (required)
Address

Street Address
City
State
Zip

Previous
Address 1		 Street Address
City
State
Zip
Home Phone
(including area code)(required)
Cell Phone
(including area code)(required)
   
Are You
A United States
Citizen?
(required)


Yes


No

 Date Of Birth
 Year
Do You
Have The Legal Right To Work In The United States?
(required)


Yes


No

 Proof Of Age
Height
(required)		 feet inches
Weight
(required)		 lbs

Are You
Now
Employed?
(required)
Yes
No		  

Position
Applied For

 Rate Of Pay Expected   $

Who Referred You?
 

PHYSICAL HISTORY

  
Do you have any physical condition which may limit your ability to perform the job applied for? (required)     Yes    No
If Yes, what can be done to accommodate your limitations?


Are you physically capable of heavy, manual work?(required) Yes    No
If No, please explain
Have you lost any time from work in the past three years?(required) Yes    No
If Yes, please explain
Would you be willing to take a physical examination?(required) Yes    No

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding three (3) years.

Applicants to drive a commercial motor vehicle (as defined by the USDOT) in intrastate or interstate commerce shall also provide an additional (7) years information on those employers for whom the applicant was an operator of a commercial motor vehicle.

Before an application is submitted, the motor carrier must inform the applicant that the information he/she provides in accordance with paragraph (b) (10) of this section may be used, and the applicant’s previous employers will be contacted, for the purpose of investigating the applicant’s safety performance history information as required by paragraphs (d) and (e) of 391.23.

MUST LIST 10 YEARS OF PREVIOUS EMPLOYMENT IN ORDER STARTING WITH MOST RECENT
 
May we contact present employer? (required)  Yes   No
  
EMPLOYER (required)
Name
Start Date
Year
Address
Street

City

State

Zip
 End Date
Year
Position Applied For
Wage
$
Phone (including area code)
Reason For Leaving
Contact Person
Were you subject to the Federal Motor Carrier Safety Registration while employed? Yes   No
Was your job designated as safety sensitive function in any DOT regulated mode subject to drug and alcohol testing? Yes   No
EMPLOYER (required)
Name
Start Date
Year
Address
Street

City

State

Zip
 End Date
Year
Position Applied For
Wage
$
Phone (including area code)
Reason For Leaving
Contact Person
Were you subject to the Federal Motor Carrier Safety Registration while employed? Yes   No
Was your job designated as safety sensitive function in any DOT regulated mode subject to drug and alcohol testing? Yes   No
EMPLOYER (required)
Name
Start Date
Year
Address
Street

City

State

Zip
 End Date
Year
Position Applied For
Wage
$
Phone (including area code)
Reason For Leaving
Contact Person
Were you subject to the Federal Motor Carrier Safety Registration while employed? Yes   No
Was your job designated as safety sensitive function in any DOT regulated mode subject to drug and alcohol testing? Yes   No
EMPLOYER (required)
Name
Start Date
Year
Address
Street

City

State

Zip
 End Date
Year
Position Applied For
Wage
$
Phone (including area code)
Reason For Leaving
Contact Person
Were you subject to the Federal Motor Carrier Safety Registration while employed? Yes   No
Was your job designated as safety sensitive function in any DOT regulated mode subject to drug and alcohol testing? Yes   No
EMPLOYER (required)
Name
Start Date
Year
Address
Street

City

State

Zip
 End Date
Year
Position Applied For
Wage
$
Phone (including area code)
Reason For Leaving
Contact Person
Were you subject to the Federal Motor Carrier Safety Registration while employed? Yes   No
Was your job designated as safety sensitive function in any DOT regulated mode subject to drug and alcohol testing? Yes   No
ACCIDENT RECORD FOR PAST 5 YEARS OR MORE
DATES
  
NATURE OF ACCIDENT/INCEDENT
FATALITIES
INJURIES
Last Accident:
Year		 YES
No		 YES
No
Next Previous:
Year		 YES
No		 YES
No
TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 5 YEARS(Other than parking violations)
LOCATION
DATE
CHARGE
PENALTY


Year


Year


Year
EXPERIENCE & QUALIFICATIONS(Driver)

DRIVER'S LICENSES
Date of each unexpired
commercial motor vehicle operator's license or permit that has been issued to the applicant
State
LICENSE NUMBER
EXPIRATION
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
C. Have you ever been convicted of a felony? Yes   No
DRIVING EXPERIENCE
Semi-Tractor Trailer Type Of Equipment
(Van-Tank-Flat-Etc)
Dates
Total # Of Miles
From To

Class A

Class B



Year

Year

Class A

Class B



Year

Year
 
List U.S. States You Have Operated In For The Last Five Years
 

In consideration for employment with PRO Resources Corporation, I hereby understand and agree as follows:

This application was completed by me, all entries upon it and information in it are true and complete to the best of my knowledge. Any false or misleading information furnished by me on this application or other required documents or in connection with my application shall result in denial of employment or, if employed by PRO Resources Corporation, the termination of my employment. PRO Resources Corporation has my consent to make a thorough investigation on my background, including my past employment, references furnished,
education and any other activities, and I release all persons, firms or entities supplying such information from any and all liability and damages on account of supplying such information. I further agree to indemnify PRO Resources Corporation against any and all liability that may result from making such an investigation.

I certify that I have not taken any non-prescribed medication during the past (60) sixty days. This includes, but is not limited to amphetamines, narcotics or any other habit-forming drug. If PRO Resources Corporation, or any of its lessees, advance me money or other items of value or I otherwise become financially indebted to PRO Resources Corporation, or any of its lessees, I agree to repay PRO Resources Corporation, or any of its lessees, and any salary or wages I earn may be used to offset (by a payroll deduction) and applied against any monies owed to PRO Resources Corporation, or any of its lessees.

This application will not be accepted or considered by PRO Resources Corporation unless all required information is completed by me and such information is fully legible. I will be given no further consideration if answers are evasive or the history of previous events is not presented in proper order with respect to dates.

I hereby authorize PRO Resources Corporation to obtain a copy of my Motor Vehicle Report. I understand that I may be on a (90) ninety day probationary period in which I may be discharged without reason or recourse.

I agree to submit to any and all testing as required by PRO Resources Corporation, any of its lessees and the Department of Transportation.

I also acknowledge and understand that I am applying for employment with PRO Resources Corporation, that if hired I will be an employee of PRO Resources Corporation, and that I can be terminated at any time with or without cause. I understand and agree that if I am employed by PRO Resources Corporation, as a condition of my employment with PRO Resources Corporation, PRO Resources Corporation has the right to transfer my services to any available position; therefore, I agree to accept a position that I am qualified to perform. In the event that training may be needed, I agree to participate in any training that may be necessary to satisfy the position.

I* (First and Last name required)
hereby certify that the information contained on the form is true and correct and that there are no omissions.
I authorize any physician, medical facility, past employer(s) and/or privileged agencies contracted by PRO Resources Corporation, to furnish or verify workers’ compensation information and medical information.

Electronic Signature*: (First and Last name required)

Email: (required)


Date*: Please select a valid item. (required)

Your ip address will be used as an additional personal identifier. Typing your name in the Electronic Signature box above is legally binding under the Uniform Electronic Transactions Act (UETA). Please check this box to show that you have read and agreed to this statement.(required)