Step 1 of 137%Pacific Excavation, Inc. is an Equal Opportunity Employer/Affirmative Action Act and will receive applicant consideration of employment without regard race, religion, color, sex (including pregnancy and gender identity), sexual orientation, parental status, national origin, age, disability, family medical history or genetic information, political affiliation, military service, or any other protected category under applicable state and or federal laws.Type of Employment Desired Full Time Seasonal Full Time or SeasonalDate MM slash DD slash YYYY Position(s) Applying ForPosition 1Position 2Position 3Position 4Personal InformationLast NameFirst NameMiddle Int.Primary PhoneAlertnate PhoneEmail Address AddressCityStateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipHave you ever been employed by Pacific Excavation, Inc.? Yes NoIf "Yes" please provide Date(s) and Positions(s)Date(s)Position(s)Reason for LeavingDate(s)Position(s)Reason for LeavingDate(s)Position(s)Reason for LeavingDate(s)Position(s)Reason for LeavingHiddenEnd Section BreakAre you 18 years of age or older to work in this industry? Yes NoAre you willing to work overtime if needed? Yes NoAre you willing to work Saturday or weekend work if needed? Yes NoDo you have a valid and current Driver’s License? Yes NoCan you perform the essential functions of this job with or without accommodations? Yes NoAdditional Comments [if needed]EMPLOYMENT HISTORYEMPLOYER 1EmployerDate Employed From MM slash DD slash YYYY Date Employed FromDate Employed To MM slash DD slash YYYY Date Employed ToAddressPhoneCityStateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipJob TitleImmediate Supervisor & Title NameSummarize the Nature of Work Performed and Job ResponsibilitiesWere you subject to the Federal Motor Carrier Safety Regulations (FMCSR) while employed? Yes NoIf “yes”, was your job designated a safety-sensitive function subject to the Drug and Alcohol Testing Requirements of 49CFR 40? Yes NoReason for LeavingDO YOU HAVE MORE EMPLOYMENT HISTORY?(Required) Yes No(You can add 3 more employers)EMPLOYER 2EmployerDate Employed From MM slash DD slash YYYY Date Employed FromDate Employed To MM slash DD slash YYYY Date Employed ToAddressPhoneCityStateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipJob TitleImmediate Supervisor & Title NameSummarize the Nature of Work Performed and Job ResponsibilitiesWere you subject to the Federal Motor Carrier Safety Regulations (FMCSR) while employed? Yes NoIf “yes”, was your job designated a safety-sensitive function subject to the Drug and Alcohol Testing Requirements of 49CFR 40? Yes NoReason for LeavingDO YOU HAVE MORE EMPLOYMENT HISTORY?(Required) Yes No(You can 2 more employers)EMPLOYER 3EmployerDate Employed From MM slash DD slash YYYY Date Employed FromDate Employed To MM slash DD slash YYYY Date Employed ToAddressPhoneCityStateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipJob TitleImmediate Supervisor & Title NameSummarize the Nature of Work Performed and Job ResponsibilitiesWere you subject to the Federal Motor Carrier Safety Regulations (FMCSR) while employed? Yes NoIf “yes”, was your job designated a safety-sensitive function subject to the Drug and Alcohol Testing Requirements of 49CFR 40? Yes NoReason for LeavingDO YOU HAVE MORE EMPLOYMENT HISTORY?(Required) Yes No(You can 1 more employer)EMPLOYER 4EmployerDate Employed From MM slash DD slash YYYY Date Employed FromDate Employed To MM slash DD slash YYYY Date Employed ToAddressPhoneCityStateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipJob TitleImmediate Supervisor & Title NameSummarize the Nature of Work Performed and Job ResponsibilitiesWere you subject to the Federal Motor Carrier Safety Regulations (FMCSR) while employed? Yes NoIf “yes”, was your job designated a safety-sensitive function subject to the Drug and Alcohol Testing Requirements of 49CFR 40? Yes NoReason for LeavingADDITIONAL EMPLOYMENT INFORMATIONProvide additional information that may be pertinent to the job you’re applying for.List reason(s) for any gaps in employment.May we contact your current & previous employers? Yes NoIf “NO”, please explain.EDUCATION / TRAINING [Including Apprenticeships and Specialized Training]High School (GED)Name & LocationCourse of Study# of Years Completed-- # of Years Completed --1234Did you Graduate?DiplomaDegreeMajorTrade / TechnicalName & LocationCourse of Study# of Years Completed-- # of Years Completed --123456789101112Did you Graduate?DiplomaDegreeMajorCollege / UniversityName & LocationCourse of Study# of Years Completed-- # of Years Completed --123456789101112Did you Graduate?DiplomaDegreeMajorCertification(s)Name & LocationCourse of Study# of Years Completed-- # of Years Completed --123456789101112Did you Graduate?DiplomaDegreeMajorEXPERIENCE: TRUCK DRIVING POSITIONSTRACTOR-TRAILER: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011DUMP TRUCK Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011READY MIX TRUCK: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011BOOM TRUCK: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011TRUCK n PUP: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011WATER TANK: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011OTHER: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011EXPERIENCE: EQUIPMENT OPERATOR POSITIONSBACKHOE: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011BOBCAT: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011LOADER: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011DOZER: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011FARM TRACTOR: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011FORKLIFT: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011ROLLER: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011MOTOR GRADER: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011PAVER/SHOVEL: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011PAVER: Type of EquipmentYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011EXPERIENCE: LABOR POSITIONSLABORER (COMMON): TasksYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011LABORER (CONCRETE): TasksYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011LABORER (GRAVEL): TasksYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011LABORER (PAVING): TasksYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011RAKER: TasksYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011FLAGGER: TasksCertification Yes NoEXPERIENCE: MAINTENANCE POSITIONSELECTRICIAN: PositionYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011MECHANIC: PositionYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011WELDING: PositionLicense TypeEXPERIENCE: OTHER POSITIONSESTIMATOR: PositionYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011DRAFTING: PositionYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011DISPATCH: PositionYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011CLERICAL: PositionYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011PURCHASING: PositionYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011PURCHASING: Underground PipeYears of Experience-- Years of Experience --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Months Of Experience-- Months Of Experience --1234567891011Experience SummaryPROFESSIONAL REFERENCES [do not list relatives or previous supervisors listed previously]NameAddressRelationshipPhoneNameAddressRelationshipPhoneNameAddressRelationshipPhoneDRIVER'S LICENSELicense NumberStateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingClassI authorize Pacific Excavation, Inc. to access my driving record:SIGNATURE:Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY AFFIDAVIT- APPLICANT’S STATEMENTI understand and agree that: Although management makes every effort to accommodate individual preferences, business need may at any time make the following conditions mandatory: overtime, shift work, weekend work, or evening work. I understand that if I am employed in an “at will “state, Pacific Excavation can change wage, benefits and employment conditions at any time. Employment with this organization is considered an “at will” state, the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. If a job offer is made by the company, I agree to submit to a post-offer, pre-employment drug screening test as a condition of employment. I understand that an offer of employment is conditioned upon the results of said testing being satisfactory to the company. I understand that any misrepresentation, material omission, or false/misleading information supplied on my application or during my interview may result in the cancellation of this application or my immediate termination of employment. My signature authorizes Pacific Excavation to make such investigation and inquiries of my personal, employment and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools or persons from all liability in rending to inquiries in connection with my application. I authorize said companies, schools or persons named in this employment application to release information regarding my employment, academic records, character and qualifications. I authorize said companies to release information from DOT regulated drug & alcohol testing records. I authorize release of alcohol tests, positive drug tests, refusal to test, other violations of DOT agency regulations, and documentation of competition of the return-to-duty following a rule violation, any other information obtained from previous employers of a drug & alcohol rule violation. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49CFR 391.23(d) and (e). I understand that I have the right to review information provided by current previous employers, have errors in the if information corrected by previous employers and for those previous employers to re-send 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. I understand the nothing contained in this employment application or in the granting of an interview creates a contract between Pacific Excavation and me for employment or for any other benefit. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon Pacific Excavation, Inc. If a conditional offer of employment is extended to me by Pacific Excavation, Inc., I understand I may be asked to authorize a background check, which may include a motor vehicle, criminal, education and employer verification and/or a credit check based on the position for which I am being considered. I have read and understand the above. I also certify that answers given herein are true and complete to the best of my knowledge. APPLICANT'S SIGNATURE:Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY ARE YOU APPLYING FOR A POSITION THAT REQUIRES DRIVING A COMPANY VEHICLE?(Required) Yes NoAFFIDAVIT TO AUTHORIZE RELEASE OF EMPLOYMENT DRIVING RECORD WITH DRUG TEST RESULT INFORMATIONComplete all information on form:I,, ofAuthorize the release of my employment driving record including drug test result to be reported to Pacific Excavation, Inc.State of IssueState of IssueAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDate of BirthDriver's License NumberThe information below will be used where applicable for request concerning your driving record to comply with DOT and state regulations.List All Unexpired Driver LicensesState of IssueStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense #TypeEndorsementExpiration DateExpiration DateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense #2State of IssueStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense #TypeEndorsementExpiration DateExpiration DateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense #3State of IssueStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense #TypeEndorsementExpiration DateExpiration DateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingHave you EVER been denied a license, permit, or privilege to operate a motor vehicle? Yes NoHas any license, permit or privilege EVER been suspended or revoked? Yes NoHave you EVER been disqualified subject to Section 391 of the Federal Motor Carrier Safety Regulations? Yes NoHave you EVER tested positive, adulterated a sample or refused a drug or alcohol test? Yes NoHave you EVER had an alcohol test with a result of 0.04 or higher? Yes NoIf any of answer to the above questions (A-E) is yes, please explain:PLEASE LIST ALL COMMERCIAL AND PRIVATE MOTOR VEHICLE ACCIDENTS FOR THE PAST 3 YEARS.LAST ACCIDENTDateNATURE OF ACCIDENT (Head On, Rear-End, Upset, Etc.)INJURIES / FATALITIESNEXT PREVIOUSDateNATURE OF ACCIDENT (Head On, Rear-End, Upset, Etc.)INJURIES / FATALITIESNEXT PREVIOUSDateNATURE OF ACCIDENT (Head On, Rear-End, Upset, Etc.)INJURIES / FATALITIESDO YOU HAVE ANY VEHICLE ACCIDENTS TO REPORT?(Required) Yes NoDO YOU HAVE ANY TRAFFIC VIOLATIONS TO REPORT?(Required) Yes NoPLEASE LIST ALL TRAFFIC VIOLATION ON YOUR RECORD DURING THE PAST 3 YEARS (Including revocation, suspension or withdrawal of an operator’s license, but no parking violations)Date MM slash DD slash YYYY OFFENSELOCATIONTYPE OF VEHICLE OPERATEDDate MM slash DD slash YYYY OFFENSELOCATIONTYPE OF VEHICLE OPERATEDDate MM slash DD slash YYYY OFFENSELOCATIONTYPE OF VEHICLE OPERATEDADDITIONAL INFORMATION<br> VOLUNTARY SELF-IDENTIFICATION FORM FOR APPLICANTSThe company is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites applicants to voluntarily self-identity their race or ethnicity along with protected Veteran status. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.Name(Last | First | Middle)Phone #Gender Male FemaleAddressCityStateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipETHNIC BACKGROUND White (not Hispanic or Latino) - A person having origins in any of the original peoples or Europe, the Middle East, or North Africa. Black or African American (not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa. American Indian or Alaskan Native (not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. Native Hawaiian or Other pacific Islanders (not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Two or More Races (not Hispanic or Latino) – All persons who identify with more than one of the above five races.This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212(VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment:Disabled Veteran: A Veteran of the U.S. Military, ground, naval or air service who is entitled to compensation ( or who but for the receipt of military retired pay would be entitled to compensation ) under laws administered by the Secretary of Veterans Affairs OR a person who was discharged or released from active duty because of a service – connected disability.Recently Separated Veteran: Any Veteran during the three-year period beginning on the date of such Veteran’s discharge or release of active duty in the U. S. Military, ground, naval, or air service.Active duty wartime or campaign badge Veteran: A Veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.Armed Forces service medal Veteran: A Veteran who, while serving on active duty in the U.S. military, ground, naval or air service participated in a United States military operation for which Armed Forces service medial was awarded pursuant to Executive Order 12985. Veteran Status: If you believe you belong to any of the categories of protected Veterans listed above, please indicate by checking the appropriate box below. As a government contractor subject to VEVRAA, we request this information to measure the effectiveness or the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.Protected Veteran I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE. I AM NOT A PROTECTED VETERAN.Protected Veterans may have additional rights under USERRA-the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty of not for the absence due to service. For more information, call the U. S. Department of Labor’s Veteran Employment a Training Service (VETS), toll-free, at 1-866-4-USA-DOL.APPLICANT'S SIGNATURE:Reset signature Signature locked. Reset to sign again Applicant’s Name (print)Date MM slash DD slash YYYY An Equal Opportunity Employer/Affirmative Action employer. All qualified and qualifiable applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, gender identity, disability, age, marital status, protected Veteran status, creed, status with regard to public assistance, sexual orientation, or any other protected category under applicable state/federal law.Δ