Work for Charbon Are you up for a challenge? Charbon Step 1 of 9 - Personal 11% Personal InformationIncomplete information may disqualify you from further consideration. Name* First Middle Last Position desired?*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Home Phone*Provide at least one phone number where you can be reached.Mobile PhoneOther PhoneWork EligibilityAre you eligible to work in the U.S?*YesNoAre you at least 18 years or older?*YesNo(If no, you may be required to provide authorization to work.)Can you work any shift?*YesNoCan you work overtime, including weekends?*YesNoAre you able to travel out of town, overnight, for extended periods of time?*YesNoHave you ever been terminated from employment or asked to resign by an employer?*YesNoIf yes, please provide company names and details.*Do you have any felony convictions?*YesNoIf yes, please explain and include approximate date(s):*We run background checks and honesty counts. Circumstances of convictions can be considered if listed here. Job DetailsIncomplete information may disqualify you from further consideration.Hourly Rate / Salary desired?*Date you can start* Date Format: MM slash DD slash YYYY Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?*YesNoAre you currently employed?*YesNoIf so, may we inquire of your present employer?*YesNoIf No, how long since your last employment?*Referral SourceHow did you hear about us?*Walk InAdvertisementReferralInternet SearchEmployment AgencyName of referrer?*Have you ever applied to work at Charbon before?*YesNoIf yes, when?*Have you ever worked for Charbon before?*YesNoIf yes, please provide start and end dates*If you went by another name when working for Charbon, please provide itDo you know anyone who works for Charbon?*YesNoIf yes, who?*Are any of them relatives?*YesNoIf yes, who?* EducationIncomplete information could disqualify you from further consideration. Fill in the applicable education and training below.High SchoolSchool NameLocationNumber of Years AttendedPlease enter a number from 0 to 99.Degree RecievedYesNoSubjects Studied / Vocational TraningCollege or UniversitySchool NameLocationNumber of Years AttendedPlease enter a number from 0 to 99.Degree RecievedYesNoSubjects Studied / MajorTrade, Business, or Correspondence SchoolSchool NameLocationNumber of Years AttendedPlease enter a number from 0 to 99.Degree RecievedYesNoSubjects Studied / MajorMilitary ServiceWere you a member of the U.S. Military Services?YesNoIf "Yes," which branch?Air ForceArmyCoast GuardMarinesNavyStart DateCurrently Active?YesNoEnd DateType of Discharge (if not currently active) Skills and ExperienceIndicate training and experience in years in the following areas and if you have received formal training:Road/Pavement markingPlease enter a number from 0 to 99.Road ConstructionPlease enter a number from 0 to 99.Concrete PumpingPlease enter a number from 0 to 99.Concrete / Flat WorkPlease enter a number from 0 to 99.PlumbingPlease enter a number from 0 to 99.ElectricalPlease enter a number from 0 to 99.WeldingPlease enter a number from 0 to 99.Military ExperiencePlease enter a number from 0 to 99.Automotive RepairPlease enter a number from 0 to 99.Engine RepairPlease enter a number from 0 to 99.HVACPlease enter a number from 0 to 99.CarpentryPlease enter a number from 0 to 99.PaintingPlease enter a number from 0 to 99.ForkliftPlease enter a number from 0 to 99.Steel WorkPlease enter a number from 0 to 99.LandscapePlease enter a number from 0 to 99.FarmingPlease enter a number from 0 to 99.Machine OperationPlease enter a number from 0 to 99.Equipment OperationPlease enter a number from 0 to 99.Admin / ClericalPlease enter a number from 0 to 99.Other Employment HistoryInclude your last seven (7) years of employment history, including periods of unemployment, starting with the most recent and working backwards in time. Incomplete information could disqualify you from further consideration. IMPORTANT: The U.S.D.O.T requires driver applicants to show all employment for the past 3 years and all commercial driving employment for the past 10 years. FMCSR 391.21(b)(10),(11).Display Employment History Forms Current or Previous Employer Previous Employer Two Previous Employer Three Select which employment forms are need below.Current or Previous EmployerIncomplete information could disqualify you from further consideration.Company Name*From*(MO / YR)To*(MO / YR)Position Held*Salary/WageReason for Leaving*Supervisor Name*Employer Phone*Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Was this position designated as a safety-sensitive function subject to DOT-Regulated drug and alcohol testing?*YesNoWhile employed by this employer, were you subject to the FMCSRs?*YesNoPrevious Employer TwoIncomplete information could disqualify you from further consideration.Company Name*From*(MO / YR)To*(MO / YR)Position Held*Salary/WageReason for Leaving*Supervisor Name*Employer Phone*Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Was this position designated as a safety-sensitive function subject to DOT-Regulated drug and alcohol testing?*YesNoWhile employed by this employer, were you subject to the FMCSRs?*YesNoPrevious Employer ThreeIncomplete information could disqualify you from further consideration.Company Name*From*(MO / YR)To*(MO / YR)Position Held*Salary/WageReason for Leaving*Supervisor Name*Employer Phone*Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Was this position designated as a safety-sensitive function subject to DOT-Regulated drug and alcohol testing?*YesNoWhile employed by this employer, were you subject to the FMCSRs?*YesNo Vehicle HistoryIndicate training, experience, and certifications you have received in the following areas:Have you ever traveled as part of your job?*YesNoIf yes, for whom?*Can you drive a manual or "stick" shift?*YesNoDo you currently have a commercial driver's license or CDL permit?*YesNoIf yes, what class is your license?*Do you understand what a "CDL" is and what is required to get one?*YesNoTypes of Vehicles DrivenHave you had experience driving equipment like the type listed below?*YesNoIf yes, please provide the correct information belowStraight Truck Type of Equipment From To Approximate Total Miles Tractor / Semi-Trailer Type of Equipment From To Approximate Total Miles Twin Trailers Type of Equipment From To Approximate Total Miles Other Equipment Type of Equipment From To Approximate Total Miles In the past 5 years, I have driven the above equipment in the following states:Special Driver-Related Courses and/or Training UndertakenSafe Driving Awards Held and Awarding OrganizationAccident Review for the Past 3 YearsPlease provide details and information below if you have had an accident in the past three (3) years.Have you had an accident in the past three years?*YesNoDisplay Accident History Forms Accident Form One Accident Form Two Accident Form Three Select which accident forms are need below.Accident Form OnePlease provide details and information below if you have had an accident in the past three (3) years.Nature of accident*Rear end, head-on collision, single carDate* Date Format: MM slash DD slash YYYY Ticketed?*YesNoFatalities*Please enter a number from 0 to 99.Injuries*Please enter a number from 0 to 99.Additional InformationAccident Form TwoPlease provide details and information below if you have had an accident in the past three (3) years.Nature of accident*Rear end, head-on collision, single carDate* Date Format: MM slash DD slash YYYY Ticketed?*YesNoFatalities*Please enter a number from 0 to 99.Injuries*Please enter a number from 0 to 99.Additional InformationAccident Form ThreePlease provide details and information below if you have had an accident in the past three (3) years.Nature of accident*Rear end, head-on collision, single carDate* Date Format: MM slash DD slash YYYY Ticketed?*YesNoFatalities*Please enter a number from 0 to 99.Injuries*Please enter a number from 0 to 99.Additional InformationTraffic Convictions and ForfeituresPlease provide details and information below if you have had any traffic violations during the past 3 years (Do not include parking tickets)Have you had any traffic violations during the past 3 years which resulted in conviction or forfeiture?*YesNoDisplay Traffic Violation Forms Traffic Violation One Traffic Violation Two Traffic Violation Three Select which traffic violation forms are need below.Traffic Violation OneLocation*Date* Date Format: MM slash DD slash YYYY Charge*Penalty*Traffic Violation TwoLocation*Date* Date Format: MM slash DD slash YYYY Charge*Penalty*Traffic Violation ThreeLocation*Date* Date Format: MM slash DD slash YYYY Charge*Penalty* Regulated Drug & Alcohol Screening HistoryEmployers subject to Federal Motor Carrier Safety Regulations must ask prospective employees about their drug and alcohol screening history during the preceding 3-year period.During the preceding 3 years, have you worked for an Employer that was DOT Regulated?*YesNoDuring the preceding 3 years, have you held a job that was designated as a "Safety Sensitive Function" in any DOT-regulated mode subject to alcohol and drug testing requirements as required by 49 CFR Part 40 of the FMCSA regulations?*YesNoDuring the preceding 3 years, have you tested positive, or refused to participate in, a drug or alcohol test administered by an employer subject to Federal Motor Carrier Safety Regulations? [A refusal includes accepting employment termination rather than participating in a test, or substituting, or otherwise tampering with a sample.]*YesNoHave you ever been denied a job with an employer subject to Federal Motor Carrier Safety Regulations because you tested positive, or failed to participate in a pre-employment drug or alcohol test?*YesNoIf you answered "YES" to question #1 and/or #2, you must provide a consent form, authorizing each former employer that met the conditions #1 and or #2, to release your Safety Performance History. You must provide that employers contact information (Address, Telephone #, Fax #). If you answered "YES" to questions #3 or #4, you must provide documentation of succesful completion of DOT's return-to-duty process before we can employ youSignature* Name Date Previous Employment with DOT-Regulated Employers (Previous 3 Years)Federal Motor Carrier Safety Regulations require prospective employers to request information from driver applicants concerning their experience driving commercially and/or working for DOT-regulated employers. Please complete the statement below, sign and date it.Have you worked for DOT-Regulated employer during the preceding 3 years?*I have worked for a DOT-Regulated employerI have no DOT-Regulated driving history nor DOT-Regulated Drug and Alcohol history to investigate for the preceding 3-year period.Signature* Name Date The U.S.D.O.T. requires driver applicants to pass certain physical test before they are hired to drive for a motor carrier. FMCSR 391(E)Date of last Department of Transportation prescribed physical examination: Date Format: MM slash DD slash YYYY Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of a foot, leg, hand, or arm?YesNoSignature* Name Date Date of Birth Health Affidavit1) Have you ever been injured in an accident?*YesNo(Home, work, sports, school, auto, other)If yes, briefly describe injury suffered:*2) Have you ever received a Worker's Compensation Payment?*YesNo3) Have you ever suffered a neck or back injury?*YesNo4) Do you now have or have you ever had any trouble with your back, other than a direct injury?*YesNo5) Have you ever had knee injury?*YesNo6) Have you ever suffered a heat related illness such as heat stroke or heat exhaustion?*YesNo7) Are you hard of hearing?*YesNo8) Date of last Tetanus shot?* Date Format: MM slash DD slash YYYY 9) Do you now have or have you ever had a hernia?*YesNo10) Do you now have or have you ever treated for heart disease or high blood pressure?*YesNo11) Do you suffer from fainting spells?*YesNo12) Do you now have or have you ever been treated for epilepsy?*YesNo13) Do you now have or have you ever been treated for diabetes?*YesNo14) Do you have any allergies?*YesNo15) Do you now have normal or corrected to normal vision?*YesNo16) Do you agree to purchase and wear required clothing on the job?*YesNo17) Do you agree to abide by the safety rules in force and practiced by this company?*YesNoComments( Apart from questions 15 through 17, please explain any answer of "Yes").Signature* Name Date ReferencesGive the names of three professional references, not related to you, whom you have known and/or worked with previously. Please provide a minimum of three (3) personal references.Display Reference Forms* Reference One Reference Two Reference Three Select which reference forms are need below.Reference OneIncomplete information could disqualify you from further consideration.Name* First Last Company NameYears Acquainted*Please enter a number from 0 to 99.Phone*Email Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference TwoIncomplete information could disqualify you from further consideration.Name* First Last Company NameYears Acquainted*Please enter a number from 0 to 99.Phone*Email Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference ThreeIncomplete information could disqualify you from further consideration.Name* First Last Company NameYears Acquainted*Please enter a number from 0 to 99.Phone*Email Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Resume(Optional)SubmitReview the terms of the Application Policy and submit for application. The application will be valid for 60 days after the date submitted.I hereby authorize Reynolds Corporation -- hereafter referred to as "Reynolds" -- to investigate my past employment, education, criminal background history, credit history, driving record, medical history, worker's compensation history, military service, and other matters as may be necessary in arriving at decision relating to my employment. Further, I release my previous employers, personal references and all other responders to Reynolds inquiries from liabilities of damages on account having furnished information about me in good faith and in accordance with applicable laws. I understand that current and/or previous employers will be contacted for the purpose of investigating my records. In particular, I authorize Reynolds to seek information concerning my criminal background history, my driving history, my safety performance history, and my participation in and results of employer drug and alcohol testing (including refusals) in accordance with Federal Motor Carrier Safety Regulations (FMCSR). Accordingly, I acknowledge my consent with special regard to government law enforcement agencies, related third party report services, and other persons or organizations holding such information about me to share these records with Reynolds, releasing them from any liability for their contributions. I acknowledge my right: 1)to review information provided by previous employers; 2) to have errors in the information corrected by previous employers and for those previous employers to resend the corrected information to the prospective employer; and 3) to 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. Should I become a Reynolds employee, I acknowledge the requirement of periodic inquiries into my FMCSR related records during and after my period of employment. Accordingly, I extend my consent and release of liability for damages regarding persons or organizations involved in sharing my FMCSR records during and beyond my period of employment. A FAX or a scanned or photographic copy of this authorization shall be as valid as the original. I acknowledge that Reynolds seeks to hire, without discrimination, only lawful workers. I hereby confirm my eligibility for legal employment within the U.S., and I understand that my identification and my eligibility for legal employment within the U.S. will be verified by the U.S. Department of Homeland Security and the Social Security Administration. I understand that I am entitled to a statement of my rights under the Fair Credit Reporting Act. I understand that information regarding sex, race and date of birth is requested in compliance with federal and state laws and will not be used to discriminate against me. I certify the accuracy and completeness of all information I provide in this application and during my subsequent interview(s). I understand that providing false or misleading information may result in rejection of my application or a termination of my employment and associated benefits in the event that I am employed with Reynolds. Finally, I understand that I am required to abide by all of Reynolds' rules and regulations. THIS APPLICATION IS VALID ONLY FOR 60 DAYS FROM THE SUBMITTED. I have read and agree to the Application Policy* I agree Signature* Name Date NameThis field is for validation purposes and should be left unchanged.
