Apply here online or in-person by calling our personnel supervisor Jon Basye and scheduling an appointment.

 

Driver's Application for Employment

APPLICANT
Applicant Name

Company: Piqua Transfer & Storage Co.

Address: P.O. Box 823

City: Piqua   State: Ohio   Zip: 45356

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

AUTHORIZATION

TO BE READ AND SIGNED BY APPLICANT
I authorize you to make such investigations and inquiries of my personal, employment, financial or medial history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) 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 understand, also, that I am required to abide by all rules and regulations of the Company.

 

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 49 CFR 391.23(d) and (e). I understand that I have the right to:

 

  • Review information provided by previous employers;
  • 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
  • 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.
Signature
APPLICANT TO COMPLETE (answer all questions)
Position(s) Applied for
Last
First
Middle
Social Security No.

List your addresses of residency for the past 3 years.

Street
City
State
Zip Code
Phone
How Long - yr/mo
APPLICANT TO COMPLETE (continued)
Date of Birth - mo/dy/year
Can you provide proof of age?
Have you worked for this company before?
Where
Dates From: mo/year
Dates To - mo/year
Rate of Pay
Position
Reason for leaving
Are you now employed?
If not, how long since leaving last employment
Who referred you
Rate of pay expected
Have you ever been bonded?
Name of bonding company
Have you ever been convicted of a felony?
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.
Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]?
If yes, explain if you wish.
EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

 

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle.

 

(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

Employer 1

EMPLOYER

Name
Address
City
State
Zip Code
Contact Person
Phone Number
Were you subject to the FMCSRs† while employed? (Select Yes/No)
Were you subject to the FMCSRs† while employed? Explain.
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?
From Month in this format 01
From Year
To Month in this format 01
To Year
Position held
Salary/Wage
Reason for leaving?
PLEASE READ

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

 

†The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

ACCIDENT RECORD (past 3 years)

Last Accident

Last Accident Date
Nature of Accident (Head-On, Rear-End, Upset, Etc..)
Fatalities
Injuries
Hazardous Material Spill
TRAFFIC CONVICTIONS (past 3 years)

Traffic Convictions and Forefeitures for the last 3 years (other than parking violations) if None, write None

Location
Date
Charge
Penalty
EXPERIENCE AND QUALIFICATIONS - DRIVER

Driver licenses or permits held in the past 3 years

State
License No.
Type
Expiration Date
A: Have you ever been denied a license, permit or privilege to operate a motor vehicle?
B: Has any license, permit or privilege ever been suspended or revoked?
If yes to either A or B, give details
DRIVING EXPERIENCE (if applicable)
Class of Equipment
List states operated in for the last five years
Show special courses or training that will help you as a driver
Which safe driving awards do you hold and from whom

Experience and qualifications - Other

Show any trucking, transportation or other experience that may help in you work for this company
List courses and training other than shown elsewhere in this application
List special equipment or technical materials you can work with (Other than those already shown)
EXPERIENCE AND QUALIFICATIONS - OTHER
Show any trucking, transportation or other experience that may help in your work for this company
List courses and training other than shown elsewhere in this application
List special equipment or technical materials you can work with (other than those already shown)