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Job Application

APPLICANT INFORMATION

Applicant Name

First

M.I.

Last

Position you would like to apply for Technician/Mechanic Driver Administrative

Date of Birth

Drivers License Number

Social Security Number

Please provide the address(es) where you have resided for the past 3 years.

Street Address

Apt. #

City

State

Zip

Number of yrs. at this address

Need to fill in another address? Yes No

Previous Address #1

Street Address

Apt. #

City

State

Zip

Number of yrs. at this address

Need to fill in another address? Yes No

Telephone

Email Address

Are you available to work Nights Weekends Over-time

Hours Full Time Part Time

Date Available

Expected rate of pay

Are you able to perform the essential job functions of the position you are applying for with or without reasonable accomodations? Yes No

Are you a citizen of the United States? Yes No

If no, are you authorized to work in the U. S.? Yes No

Will you require sponsorship in the future? Yes No

Have you previously applied at this company? Yes No

If yes, what dates?

Have you ever been employed by this company? Yes No

If yes, provide dates of employment, location, and reason for separation from employment below.

Criminal convictions or arrests will not automatically disqualify an applicant from a particular job. The Company will consider the nature of the crime, its seriousness, the substantial relation to the position`s function and qualifications, the number of occurrences, the applicants`s age at the time of the crime, the time elapsed since the crime, the applicant`s entire work and educational history, employment references and recommendations, and the business necessity of any exclusion when required by law.

Have you been convicted of a felony within the last seven (7) years? Yes No

If yes, please provide the date(s) and explain in accordance so that individual circumstances can be considered. A `yes` answer will not necessarily disqualify you from employment.

Have you ever initiated an act of violence in the workplace? Yes No

If yes, please provide the date(s) and explain in accordance so that individual circumstances can be considered. A `yes` answer will not necessarily disqualify you from employment.

EDUCATION

Highest Level of Education Completed High School College

Please Provide Type of Degree or Diploma Received

Bus./Tech./Trade School

City/State

Did you Graduate? Yes No

List all job related certificates, and professional organizations:

GENERAL INFORMATION

Military Branch

Dates Served

Military Rank

If discharged, was discharge voluntary? Yes No

Do you have any relatives that are or have been employed by D.W. Cary Hauling, Inc.? Yes No

If yes, please list their name(s) below.

EXPERIENCE / SKILLS

Administrative

How many years of experience do you have working in an administrative capacity?

Please check all that apply Answering multi-line telephone systems Microsoft Excel Microsoft Outlook Microsoft Word 10 stroke key punch Data Entry Copy Machines Typing Facsimile

Driver/Technician

Driving

Do you have a CDL? Yes No

Class Type? Class A Class B Neither

Provide the issuing state, number, and expiration date of each unexpired commercial motor vehicle operator’s license or permit that has been issued to you.

Commercial Motor Vehicle Operator License Number

Issuing State

Expiration Date

Need to fill in other expired license information? Yes No

Provide the issuing state, number, and expiration date of each unexpired commercial motor vehicle operator’s license or permit that has been issued to you.

Additional Commercial Motor Vehicle Operator License Number

Additional Issuing State

Additional Expiration Date

Check all boxes that apply Dump Trucks Dump Trailers Excavator Front End Loader Rubber Tire Loader Rubber Tire Backhoe

Technician

Check all boxes that apply State Inspection License Welding & Fabrication Air Brake Repair Routine Preventative Maintenance Hydraulic And Engine Repairs Chassis Repair Fuel Injection Systems Repairs Transmission Repairs Electrical System Repairs Tire Repair

Motor Vehicle Information

Have you been employed in a DOT regulated position where you were subject to drug and alcohol testing? Yes No

At any time, were you ever convicted of driving with an expired license, a revoked license or driving without a license? Yes No

At any time, has your license, permit or privilege to operate a motor vehicle been denied, revoked, or suspended? Yes No

If yes, please provide detailed facts and circumstances of any denial, revocation, or suspension of any license, permit or privilege to operate a motor vehicle.

In the last three years, have you been involved in any motor vehicle accidents? Yes No

If yes, please provide a list of all motor vehicle accidents including the date, nature of each accident and any fatalities or personal injury caused.

In the last three years, have you been convicted or forfeited bond or collateral due to a motor vehicle violation of the law or ordinances (other than violations involving only parking)? Yes No

If yes, please provide a list of all violations.

Within the last five years, have you been convicted of operating a motor vehicle while under the influence of a controlled substance and/or alcohol? Yes No

If yes, please provide a statement detailing the circumstances.

Do you currently have any pending charges related to driving with an expired license, a revoked license or driving without a license? Yes No

Do you currently have any pending charges related to operating a motor vehicle, while under the influence of a controlled substance and/or alcohol? Yes No

At any time, have you been convicted of carelessly or recklessly driving a motor vehicle? Yes No

Do you currently have any pending charges related to operating a motor vehicle carelessly or recklessly? Yes No

During pre-employment for a DOT mandated drug or alcohol test, at any time, have you ever refused to test or tested positive for drugs or alcohol? Yes No

At any time, while on-the job, were you convicted of any illegal substances inclusive of amphetamines, marijuana, etc.? Yes No

Do you currently have any pending charges related to any illegal substance inclusive of amphetamines, marijuana, etc.? Yes No

PREVIOUS EMPLOYMENT (must include last 10 years)

Company

Telephone

Address

City and State

Zip Code

Job Title

Supervisor

Starting Salary $

Ending Salary $

Was your position subject to FMCSRs? Yes No

Was the position subject to DOT regulated alcohol and controlled substances testing requirement? Yes No

Responsibilities

From

Reason For Leaving

May we contact your previous supervisor for a reference? Yes No

Company

Telephone

Address

City and State

Zip Code

Job Title

Supervisor

Starting Salary $

Ending Salary $

Was your position subject to FMCSRs? Yes No

Was the position subject to DOT regulated alcohol and controlled substances testing requirement? Yes No

Responsibilities

From

Reason For Leaving

May we contact your previous supervisor for a reference? Yes No

Company

Telephone

Address

City and State

Zip Code

Job Title

Supervisor

Starting Salary $

Ending Salary $

Was your position subject to FMCSRs? Yes No

Was the position subject to DOT regulated alcohol and controlled substances testing requirement? Yes No

Responsibilities

From

Reason For Leaving

May we contact your previous supervisor for a reference? Yes No

Company

Telephone

Address

City and State

Zip Code

Job Title

Supervisor

Starting Salary $

Ending Salary $

Was your position subject to FMCSRs? Yes No

Was the position subject to DOT regulated alcohol and controlled substances testing requirement? Yes No

Responsibilities

From

Reason For Leaving

May we contact your previous supervisor for a reference? Yes No

Have you ever been terminated or asked to resign from any job? Yes No

If yes, please explain below.

Have you ever received a verbal or written warning? Yes No

If yes, please explain below.

REFERENCES

Please list three references of former managers/supervisors who are NOT related to you.

Full Name

Relationship

Company

Telephone

Company Address

City/State

Zip Code

Full Name

Relationship

Company

Telephone

Company Address

City/State

Zip Code

Full Name

Relationship

Company

Telephone

Company Address

City/State

Zip Code

DRUG AND ALCOHOL TESTING / RELEASE OF DRIVING

In the event that the company determines that I am eligible for an offer of employment, I understand that I may be required to participate in blood and/or urine for alcohol, chemical dependency or other substance abuse. I consent to administration of such testing and understand that in addition to testing as a part of the application or hiring process, I may be subject to future random testing and testing `for cause,` which may include involvement in job-related accidents, suspicious behavior, etc. I understand that in the event that I refuse to consent to such a test or violate the Company’s drug and alcohol policy, or test positive for substance abuse or chemical dependency, my application for employment will be disqualified from further consideration or my employment will be terminated without notice. Accommodation will be made for the use of legally prescribed medication taken under the direction of a physician.

I Agree

AUTHORIZATION TO RELEASE DRIVING RECORD: I hereby authorize D.W. Cary Hauling Inc. and its agents to request periodically any information concerning my driving record. I hereby authorize any persons having knowledge thereof to provide such information to D.W. Cary Hauling Inc. and/or its agents, and I hereby agree to release from liability and agree to hold harmless any person who furnishes such information in good faith.

I Agree

EMPLOYEE REFERRAL

How did you hear about us?

Were you referred by anyone? Yes No

If yes, please provide his/her name

OPTIONAL QUESTIONNAIRE

D. W. Cary Hauling, Inc is an equal opportunity employer. We have provided a voluntary section below for you to enter self-identifying information. This information is not used to make a hiring decision, but rather to gather information for record keeping and governmental reporting purposes.

Veteran/Disability

Vietnam Era Veteran

Special Disabled Veteran

Other Protected Veteran

Newly Separated Veteran

Disabled

None

Gender

Male

Female

Opt not to disclose

Race

Opt not to disclose

White (Non-Latino or Hispanic)

Black/African American (Non-Latino or Hispanic)

Asian (Non-Latino or Hispanic)

Hispanic or Latino

Native American or other Pacific Islander (Non-Latino or Hispanic)

American Indian or Alaska Native (Non-Latino or Hispanic)

Two or more races (Non-Latino or Hispanic)

DISCLAIMER AND SIGNATURE

D.W. Cary Hauling, Inc. is an equal opportunity employer. D.W. Cary Hauling, Inc. does not discriminate with regard to race, color, religion, creed, national origin, age, or sex.

If hired, I understand that D.W. Cary Hauling, Inc. may terminate my employment at any time and for any reason, with or without cause, and without prior notice. I understand that no representative of D.W. Cary Hauling, Inc. has the authority to make any assurance to the contrary.

I have given D.W. Cary Hauling, Inc. true and complete information on this application. No information has been concealed. I authorize D.W. Cary Hauling, Inc. to conduct reference checks, criminal background checks, DMV history and drug testing. Any information found to be false or concealed, will constitute cause for denial of employment or immediate dismissal.

I understand that should employment be offered and accepted by me, I will fully adhere to the policies, rules and regulations of the employer. I further understand that neither the policies, rules, regulation of employment nor anything discussed during the interview process shall be deemed to constitute the terms of implied employment.

I further understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause.

D.W. Cary Hauling, Inc. is an equal opportunity employer. D.W. Cary Hauling, Inc. does not discriminate with regard to race, color, religion, creed, national origin, age, or sex.

I certify that I have read and understand all of this employment application. It is agreed and understood that the employer or his agents may investigate the applicant’s background to ascertain any and all of the information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and other persons names herein from all liability for any damages on account of his furnishing such information. I understand that, as an applicant for a position with this company. I may be asked to demonstrate that I am capable of performing tasks that are pertinent to the job.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, personal reputation, personal characteristics and mode of living.

I further understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Please attach your resume, cover letter, reference letters, medical cards and certifications here. Attaching your motor vehicle record could expedite the review process. (Must be in the one of the following formats: zip,pdf,doc,jpg,jpeg,gif,png,docx)

Signature

Date

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11520 Fox Cross Road • Ashland, VA 23005 • P: 804-798-4777 • F: 804-798-4772
Office Hours: 8am - 4:30pm • Shop and Dispatch Hours: 6am - 6pm