Employment Application

An Equal Opportunity Employer. We consider applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, sexual orientation, citizen status, genetic ininformation or any other legally protected status.

PERSONAL INFORMATION

Name

First Middle Last

Social Security No.

Address

Street Address Address Line 2 City State ZIP Code

Primary Phone

Secondary Phone

Email

How were you referred?

GENERAL INFORMATION

Are you under the age of 18?

Yes
No

If so, Can you supply working papers?

Yes
No

U.S. Citizens or aliens who have the legal right to work in the U.S. are eligible for employment. Upon employment, can you provide genuine documentation establishing your identity?

Yes
No

A conviction record will not necessarily negate your chances of employment. Factors such as job relations, age, time of offense, seriousness, nature of violation, and rehabilitation will all be considered.

Have you ever been convicted of a felony?

Yes
No

If Yes, please explain.

Have you ever been discharged from employment or forced to resign?

Yes
No

If Yes, please explain.

IF YOU HAVE ANY QUESTIONS CONCERNING THE POSITION, PLEASE ASK THE INTERVIEWER BEFORE ANSWERING.

JOB INTEREST

Type of work desired

Position(s) desired

Wage Desired

Date Available to Start

Work Availability

Please check all that apply.

Full
Part
Overtime, if required
Weekends, if required
Seasonal
Temporary

Conditions of employment are listed at the end of this form. Please read carefully before you sign this application. Application must be completed in full even if attaching a resume. Job applications are considered active for 60 days, after which, the applicant must reapply for further consideration.

EMPLOYMENT HISTORY

Begin with your most recent employment, continuing with your past employment for the last 5 years. All Driver Applicants must provide information on all previous employers for the last three years. List the complete mailing address including street number, city, and zip code. Applicants driving a commercial motor vehicle in interstate or intrastate must provide an additional 7 years of information.

Employer Name

Job Title

Dates Employed

Employer Address

Description of Duy

Starting Wage

Ending Wage

Employer Phone No.

Reason for leaving

May we contact?

Yes
No

Explanation of any period between jobs:

Were you subject to the FMCSR during this employment?

Yes
No

Was your job designated a safety sensitive function?

Yes
No

Were you subjected to DOT regulated drug and alcohol testing requirements of 49 CFR Part 40?

Yes
No

Employer Name

Job Title

Dates Employed

Employer Address

Description of Duy

Starting Wage

Ending Wage

Employer Phone No.

Reason for leaving

May we contact?

Yes
No

Explanation of any period between jobs:

Were you subject to the FMCSR during this employment?

Yes
No

Was your job designated a safety sensitive function?

Yes
No

Were you subjected to DOT regulated drug and alcohol testing requirements of 49 CFR Part 40?

Yes
No

Employer Name

Job Title

Dates Employed

Employer Address

Description of Duy

Starting Wage

Ending Wage

Employer Phone No.

Reason for leaving

May we contact?

Yes
No

Explanation of any period between jobs:

Were you subject to the FMCSR during this employment?

Yes
No

Was your job designated a safety sensitive function?

Yes
No

Were you subjected to DOT regulated drug and alcohol testing requirements of 49 CFR Part 40?

Yes
No

DRIVING INFORMATION

Any applicant applying for a position requiring driving must complete the following section. Accident record for the previous 5 years.

License Type

Issuing State

License No.

Expiration Date

Driving Incidents:

Date of Accident

Type of Accident

Fatalities or Injuries

Yes
No

Hazardous Material Spill

Yes
No

Date of Accident

Type of Accident

Fatalities or Injuries

Yes
No

Hazardous Material Spill

Yes
No

Date of Accident

Type of Accident

Fatalities or Injuries

Yes
No

Hazardous Material Spill

Yes
No

If any, Please explain:

Traffic Convictions for the last 3 years:

Date

Location

Charge

Penalty

Date

Location

Charge

Penalty

Date

Location

Charge

Penalty

If any, Please explain:

Driving Experience:

Straight Truck:

FROM

TO

Approximate Miles Driven

Tractor & Semitrailer:

FROM

TO

Approximate Miles Driven

Tractor & Two Trailers:

FROM

TO

Approximate Miles Driven

Tractor & Triple Trailers:

FROM

TO

Approximate Miles Driven

Other:

FROM

TO

Approximate Miles Driven

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

Yes
No

Has your license, permit, or privilege ever been cancelled, denied, suspended, or revoked?

Yes
No

Have you ever tested positive for alcohol or a controlled substance?

Yes
No

Have you ever been convicted or pled guilty or no contest to a DWI/DUI or any drug or alcohol related offense?

Yes
No

Are you currently taking any medications prescribed or otherwise that could affect your ability to drive a vehicle safely?

Yes
No

If you answered yes to any of the above questions, please provide details:

List any driving classes or awards you have received:

EDUCATION

High School, Graduated:

Yes
No

Name & Address:

Degree:

College, Graduated:

Yes
No

Name & Address:

Degree:

Graduate School, Graduated:

Yes
No

Name & Address:

Degree:

Trade School, Graduated:

Yes
No

Name & Address:

Degree:

Other, Graduated:

Yes
No

Name & Address:

Degree:

REFERENCES

Name

Phone No.

Relationship

Years Known

Name

Phone No.

Relationship

Years Known

Name

Phone No.

Relationship

Years Known

Name

Phone No.

Relationship

Years Known

ADDITONAL QUALIFICATIONS OR EXPERIENCE

List any other Skills, Qualifications, or Experience you believe will help you in being considered for the position you applied for.

Skills

Qualification

Experience

ADDITIONAL COMMENTS OR CONCERNS

Conditions of employment are listed at the end of this form. Please read carefully before you sign this application. Application must be completed in full even if attaching a resume. Job applications are considered active for 60 days, after which, the applicant must reapply for further consideration.

NOTIFICATION AND AGREEMENT

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE, AND COMPLETE. I UNDERSTAND THAT THE FALSIFICATION, MISREPRESETNATION, OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED. Questions regarding this statement should be directed to any employment interviewer before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed. It is the policy of Lee Supply Company, Inc. to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State, or Local law. I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation. I hereby certify that all the facts and information listed on this employment application are true and complete. I understand that any false, incomplete, or misleading information given by me on this application is sufficient cause for rejection of this application. I also understand and agree that any such false, incomplete, or misleading information discovered on this application at any time after I am employed my result in dismissal. If I am offered employment, I understand that such an offer will be conditioned upon satisfactory results of a background investigation and/or company medical examination or inquiry, including a drug-screening test. I consent to the investigation, physical and drug test. I hereby authorize Lee Supply Company, Inc. to investigate all statements contained in this application, to interview the references and previous employers listed in the application (unless otherwise noted), and to obtain a report from a consumer- reporting agency to be used for employment purposes in accordance with the Fair Credit Reporting Act. I authorize the references and previous employers listed to give Lee Supply Company, Inc. all facts, opinions, and evaluations concerning my previous employment and any other information they may have, personal or otherwise, and release all such information to Lee Supply Company, Inc., including, but not limited to, any liability or invasion of privacy. I understand that I will be provided with a separated consent form authorizing a consumer report and/or investigative consumer report. If I am applying for a position as a driver with Lee Supply Company, Inc., I understand that information I provide regarding current and/or previous employers may be used, and those employers contacted for investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: a) Review information provided by previous employers; b) Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer, and; c) 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. In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice at any time by the company. I further understand and voluntarily agree as a condition of employment or my continued employment, that I may be requested by Lee Supply Company, Inc. to submit to a urinalysis or other drug screen test and that my failure to take such test(s) when requested to do so or unsatisfactory test results will disqualify me from consideration for employment, or if I am then employed, may result in immediate dismissal. I acknowledge that I have a valid driver’s license in one of the 50 United States. I acknowledge that I have read and understand the above statements and herby grant permission to confirm the information supplied on this application by me.

Name

First Last

Date

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Phone

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