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APPLICATION FOR EMPLOYMENT

NAME

ADDRESS

PREVIOUS THREE YEARS RESIDENCY

(Attach Sheet if More Space Is Needed)

LICENCE INFORMATION

Section 383.21 FMCSR  states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license, the information for which is listed below

DRIVING EXPERIENCE

Class of Equipment

Type of Equipment (Van, Tank, Flat, Etc.)

Dates From | To

Approx. No. of Miles (total)

Straight Truck

Tractor and Semi-Trailer

Tractor - Two Trailers

Other

Accident Record for Past 3 Years or More (attach Sheet if More Space Is Needed) 

Dates

Nature of Accident  (head-On, Rear-End, Upset, Etc.)

Number Fatalities

Number Injuries

Chemical Spills

YES
NO
YES
NO
YES
NO

Traffic Convictions and Forfeitures for The Past 3 Years (other than Parking Violations) 

Dates Convicted

(month/year) 

Violation

State of Violation 

Penalty

(forefeited bond, collateral and/or points)

(Attach Sheet if More Space Is Needed) 

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?

EMPLOYMENT RECORD 

(Attach Sheet if More Space Is Needed)

Must list the complete mailing address: street number and name, city, state and zip code.

YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO

TO BE READ AND SIGNED BY APPLICANT 

I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical 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, healthcare 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 current/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.”

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 information in addition to the information required by the Federal Motor Carrier Safety Regulations. 

We are always looking to hire experienced concrete pump operators in Baton Rouge. Fill out our online application today!

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