EHC Construction, Inc.2945 Van Buren St. Fort Myers, FL 33916 239-592-0828 Applicant Information Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Social Security Number Today's Date * MM DD YYYY Position Applied For * Date Available * MM DD YYYY Do you have a legal right to work in the United States? * Yes No Previous Three Years Residency Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Number of Years at Current Address * Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Number of Years at Mailing Address * Previous Address 1 Address 1 Address 2 City State/Province Zip/Postal Code Country Number of Years at Previous Address 1 Previous Address 2 Address 1 Address 2 City State/Province Zip/Postal Code Country Number of Years at Previous Address 2 Previous Address 3 Address 1 Address 2 City State/Province Zip/Postal Code Country Number of Years at Previous Address 3 Current License Information State * AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY License Number * Type/Class * Endorsements Expiration Date * MM DD YYYY Previously Held License Information 1 State * AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY License Number Type/Class Endorsements Expiration Date MM DD YYYY Previously Held License Information 2 State * AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY License Number Type/Class Endorsements Expiration Date MM DD YYYY Driving Experience Straight Truck Type of Equipment (Van, Tank, Flat, etc.) From Date MM DD YYYY To Date MM DD YYYY Approx. # of Total Miles Tractor & Semi-Trailer Type of Equipment (Van, Tank, Flat, etc.) From Date MM DD YYYY To Date MM DD YYYY Approx. # of Total Miles Tractor & 2 Trailers Type of Equipment (Van, Tank, Flat, etc.) From Date MM DD YYYY To Date MM DD YYYY Approx. # of Total Miles Tractor & Tanker Type of Equipment (Van, Tank, Flat, etc.) From Date MM DD YYYY To Date MM DD YYYY Approx. # of Total Miles Other Type of Equipment (Van, Tank, Flat, etc.) From Date MM DD YYYY To Date MM DD YYYY Approx. # of Total Miles Accident Record for the Past Three Years Check this box if none None Accident 1 (Most Recent) Date MM DD YYYY Nature of Accident (Head-on, rear-end, upset, etc.) Number of Fatalities Number of Injuries Chemical Spill? Yes No Accident 2 Date MM DD YYYY Nature of Accident (Head-on, rear-end, upset, etc.) Number of Fatalities Number of Injuries Chemical Spill? Yes No Accident 3 Date MM DD YYYY Nature of Accident (Head-on, rear-end, upset, etc.) Number of Fatalities Number of Injuries Chemical Spill? Yes No Traffic Convictions and Forfeitures for the Past Three Years (non-parking violations) Check this box if none None Incident 1 (Most Recent) Date Convicted MM DD YYYY Violation State of Violations Penalty (Forfeited bond, collateral, and/or points) Incident 2 Date Convicted MM DD YYYY Violation State of Violations Penalty (Forfeited bond, collateral, and/or points) Incident 3 Date Convicted MM DD YYYY Violation State of Violations Penalty (Forfeited bond, collateral, and/or points) Have you ever been denied a license, permit, or privilege to operator a motor vehicle? Yes No If yes, explain Has any license, permit, or privileges ever been suspended or revoked? Yes No If yes, explain Employment History The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information. Current (Most Recent) Employer Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Position Held From Date MM DD YYYY To Date MM DD YYYY Reason for Leaving Salary Explain Any Gaps in Employment (Include month/year and reason) While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No Was the job designated as a safety sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? Yes No Second Most Recent Employer Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Position Held From Date MM DD YYYY To Date MM DD YYYY Reason for Leaving Salary Explain Any Gaps in Employment (Include month/year and reason) While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No Was the job designated as a safety sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? Yes No Third Most Recent Employer Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Position Held From Date MM DD YYYY To Date MM DD YYYY Reason for Leaving Salary Explain Any Gaps in Employment (Include month/year and reason) While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No Was the job designated as a safety sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? Yes No Education High School Name and Location Course of Study Years Completed Graduated Yes No Details College Name and Location Course of Study Years Completed Graduated Yes No Details Other Name and Location Course of Study Years Completed Graduated Yes No Details Please list any other qualifications that you have which you believe should be considered To Be Read and Acknowledged by Applicant I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to: • Review information provided by current/previous employers; • Have errors in the information corrected by previous employers, and for those previous employers to resend 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. This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations. Check this box to acknowledge the above message * Acknowledge Today's Date * MM DD YYYY Thank you!
