Print and complete this form, and submit it to the address at the bottom of this page.
Applicants are considered without regard to race, creed, color, sex, religion, age, national origin or disability.
POSITION: Owner/Operator Today's Date:
Name (first, middle, last): SS#:
Email Address:
Present Address: City: State: Zip: Phone:
Best time to call:
Permanent Address: City: State: Zip: Phone:
Residence for past 3 years: City: State: Zip: Phone:
Date of birth: Place of birth: U.S. Citizen: (yes/no) Height: Weight:
marital status: number of dependents:
Name of Father: Address (St., City, State, Zip) Phone: Occupation: Company Employed:
Name of Mother: Address (St., City, State, Zip) Phone: Occupation: Company Employed:
Name of Spouse: Address (St., City, State, Zip) Phone: Occupation: Company Employed:
List all drivers licenses held in past five (5) years
State: License Number: Type: Endorsements: Exp Date: Birth Date:
State: License Number: Type: Endorsements: Exp Date: Birth Date:
State: License Number: Type: Endorsements: Exp Date: Birth Date:
Have you ever worked for this company before? (Y/N) If Yes, When? Have you previously applied for employment with this company? (Y/N) If Yes, When? Names of relatives currently employed with company:
Begin with your present or most recent job and work backward in order, listing your employers for at least the past 10 years including all full-time and part-time employment. All time must be accounted for including military service, self-employment and periods of unemployment.
WE MUST HAVE TELEPHONE NUMBERS AND PERIODS OF UNEMPLOYMENT.
Current or Most Recent Employer
Employer:
Address:
City: State: Zip:
Phone: Supervisor:
May we call? (Y/N)
Dates Employed: to
Position held: Rate of Pay:
Reason for Leaving?
Number of states driven in
Number of Accidents Please Explain
Second Last Employer
Employer:
Supervisor:
Address:
City: State: Zip:
Phone:
Dates Employed: to
Position held: Rate of Pay:
Reason for Leaving?
Number of states driven in
Number of Accidents Please Explain
Third Last Employer
Employer:
Supervisor:
Address:
City: State: Zip:
Phone:
Dates Employed: to
Position held: Rate of Pay:
Reason for Leaving?
Number of states driven in
Number of Accidents Please Explain
Fourth Last Employer
Employer:
Supervisor:
Address:
City: State: Zip:
Phone:
Dates Employed: to
Position held: Rate of Pay:
Reason for Leaving?
Number of states driven in
Number of Accidents Please Explain
Fifth Last Employer
Employer:
Supervisor:
Address:
City: State: Zip:
Phone:
Dates Employed: to
Position held: Rate of Pay:
Reason for Leaving?
Number of states driven in
Number of Accidents Please Explain
Sixth Last Employer
Employer:
Supervisor:
Address:
City: State: Zip:
Phone:
Dates Employed: to
Position held: Rate of Pay:
Reason for Leaving?
Number of states driven in
Number of Accidents Please Explain
Seventh Last Employer
Employer:
Supervisor:
Address:
City: State: Zip:
Phone:
Dates Employed: to
Position held: Rate of Pay:
Reason for Leaving?
Number of states driven in
Number of Accidents Please Explain
TRAFFIC CONVICTIONS/FORFEITURES List ALL vehicle moving traffic convictions and forfeitures for the past five years (IF NONE, TYPE NONE)
Date location (state) charge penalty
Date location (state) charge penalty
Date location (state) charge penalty
Date location (state) charge penalty
Date location (state) charge penalty
ACCIDENT REPORT List ALL accidents/incidents with vehicles for the past 5 years, includepreventable and non-preventable, WHETHER OR NOT ON MVR.
Date: Type of vehicle: Nature of accident: (head on, rear-end, upset, etc.) Preventable (P) or Non-preventable (N) Fatalities: (Y/N) Injuries: (Y/N) Amount of property damage:
Date: Type of vehicle: Nature of accident: (head on, rear-end, upset, etc.) Preventable (P) or Non-preventable (N) Fatalities: (Y/N) Injuries: (Y/N) Amount of property damage:
Date: Type of vehicle: Nature of accident: (head on, rear-end, upset, etc.) Preventable (P) or Non-preventable (N) Fatalities: (Y/N) Injuries: (Y/N) Amount of property damage:
Date: Type of vehicle: Nature of accident: (head on, rear-end, upset, etc.) Preventable (P) or Non-preventable (N) Fatalities: (Y/N) Injuries: (Y/N) Amount of property damage:
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? (Y/N) B. Have you ever had any license, permit or privilege suspended or revoked? (Y/N) C. Have you ever been convicted for driving while under the influence of alcohol or drugs? (Y/N) D. Have you ever been convicted for possession, sale, or use of a narcotic drug, amphetamine, or derivative thereof? (Y/N) E. Have you ever been refused liability insurance? (Y/N) F. Have you ever been convicted of a Felony? (Y/N) G. Have you ever been convicted of a Misdemeanor? (Y/N) H. Have you ever been disqualified to drive by Federal Regulations? (Y/N) I. Have you ever been refused a security bond? (Y/N) If answer to any question is yes, state details, circumstances, and date:
List last three (3) schools attended, starting with the most recent.
Name: City: State: Years Completed: Degree/Diploma: Major: Minor:
Name: City: State: Years Completed: Degree/Diploma: Major: Minor:
Name: City: State: Years Completed: Degree/Diploma: Major: Minor:
Name: City: State: Years Completed: Degree/Diploma: Major: Minor:
Name: City: State: Graduation Date:
Have you served in the U.S. Armed Forces? Yes No
Branch? Dates: From To
DD214 Narrative reason for discharge
Honorable discharge? Yes No
Do you have a DD214? Yes No
EXLUDE INFORMATION WHICH WOULD REVEAL SEX, RACE, RELIGION, NATIONAL ORIGIN, AGE, COLOR, DISABILITY OR ANY OTHER SIMILARLY PROTECTED STATUS.
I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer's service, whenever it is discovered.
I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the informaiton contained in this applications. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations or ogranizations for furnishing such information.
The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law.
This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.
If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer.
I understand it is this company's policy not to refuse to hire a qualified individual with a disability because of that person's need for a reasonable accomodation as required by the ADA.
I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.
Final employment offer is contingent upon passing physical and drug screen. (Alcohol testing included when legal). I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.
Equal Opportunity Employer
To submit to become a Terrier Transportation Owner/Operator:
A. Print out and fax to (713) 671-2070
Attn: Driver Recruiting
B. Print out and mail to:
Terrier Transportation, Inc.
Driver Recruiting
4708 Fidelity
Houston, TX 77029
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