DRIVER'S
APPLICATION FOR EMPLOYMENT

Company : KEITH HALL & SONS TRANSPORT LTD
Address : 297 BISHOPSGATE ROAD
City : BURFORD State : ON Zip : N0E 1A
(answer all questions - please print)

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, or non-job related disability.

Date of application
Position(s) Applied for
Name Social Security No.

List your addresses of residency for the past 3 years.

Current Address  
Previous Addresses
Phone How Long?
Do you have the legal right to work in the United States? Yes No
Date of Birth Can you provide proof of age? Yes No

Have you worked for this company before? Yes No Where?
Dates: From To Rate of Pay Position
Reason for leaving
Are you now employed? Yes No If not, how long since leaving last employment'
Who referred you? Rate of pay expected
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]?
Yes No
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 year's 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 DATE
NAME
From
To
ADDRESS
POSITION HELD
SALARYNVAGE
CONTACT PERSON PHONE NUMBER
REASON FOR LEAVING
EMPLOYER DATE
NAME
From
To
ADDRESS
POSITION HELD
SALARYNVAGE
CONTACT PERSON PHONE NUMBER
REASON FOR LEAVING
EMPLOYER DATE
NAME
From
To
ADDRESS
POSITION HELD
SALARYNVAGE
CONTACT PERSON PHONE NUMBER
REASON FOR LEAVING
EMPLOYER DATE
NAME
From
To
ADDRESS
POSITION HELD
SALARYNVAGE
CONTACT PERSON PHONE NUMBER
REASON FOR LEAVING
EMPLOYER DATE
NAME
From
To
ADDRESS
POSITION HELD
SALARYNVAGE
CONTACT PERSON PHONE NUMBER
REASON FOR LEAVING

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.


ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) 1F-NONE, WRITE NONE

DATES NATURE OF ACCIDENT
(HEAD-ON, REAR-END, UPSET ETC.)
FATALITIES INJURIES
LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

LOCATION DATE CHARGE PENALTY

(ATTACH SHEET IF MORE SPACE IS NEEDED)

EDUCATION

CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 9 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4
LAST SCHOOL ATTENDED

EXPERIENCE AND QUALIFICATIONS - DRIVER

DRIVER
LICENSES
STATE LICENSE NO. TYPE EXPIRATION DATE
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO
B. Has any license, permit or privilege ever been suspended or revoked? YES NO
IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS

DRIVING EXPERIENCE IF NONE, WRITE NONE

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
MOTORCOACH - SCHOOL BUS
OTHER

LIST STATES OPERATED IN FOR 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 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)

TO BE READ AND SIGNED BY APPLICANT

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.

authorize you to make such investigations and inquiries of 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, 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.

 
Date   Applicant's Signature

PROCESS RECORD

APPLICANT HIRED REJECTED
DATE EMPLOYED POINT EMPLOYED
DEPARTMENT CLASSIFICATION
(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)
THIS SECTION TO BE FILLED IN BY RESPONSIBLE
OFFICER OR COMPANY REPRESENTATIVE

  SUPERIOR GOOD FAIR BELOW AVERAGE POOR WRITTEN RECORD ON FILE
1.APPLICATION
2.INTERVIEW
3.PAST EMPLOYMENT
4.WRITTEN EXAM
5.ROAD TEST
6.CRIMINAL AND TRAFFIC CONVICTIONS

SIGNATURE OF INTERVIEWING OFFICER

TRANSFERS

FROM: TO:
DATE:
REASON FOR TRANSFER
FROM: TO:
DATE:
REASON FOR TRANSFER
FROM: TO:
DATE:
REASON FOR TRANSFER
FROM: TO:
DATE:
REASON FOR TRANSFER

TERMINATION OF EMPLOYMENT

DATE TERMINATED DEPARTMENT RELEASED FROM
DISMISSED VOLUNTARILY QUIT OTHER
TERMINATION REPORT PLACED IN FILE SUPERVISOR


CONSENT FORM

Within 45 days of receiving a complete petition, FMCSA will inform the driver in writing of its decision to remove, retain, or correct the information in the database and provide the basis for the decision.

Driver Consent to Permit Access to Information in the Clearinghouse

The Company will not query the Clearinghouse to determine whether a record exists for any particular driver without first obtaining that driver's written or electronic consent. Before the Company accesses information contained in the driver's Clearinghouse record, the driver must submit electronic consent through the Clearinghouse. The Company will not permit a driver to perform a safety-sensitive function in or respecting the United States if the driver refuses to grand consent.

Compliance with Laws

Nothing in this Addendum is intended or should be interpreted as being inconsistent with the Company's legal obligations under any applicable laws, including but not restricted to applicable human rights legislation, privacy legislation, FMCSA or U.S. DOT regulations or rules, which are in existence or which are changed or com into existence in future ("Laws"). If such an inconsistency is identified or arises, a correction of that inconsistency is to be automatically read into this Addendum. If in any individual circumstance of the actual application of this Addendum, the application of any provision of this Addendum would result in an inconsistency with the Company's obligations under any Laws, the Addendum is to be automatically applied in a manner consistent with such laws.

Acknowledgement

I hereby acknowledge and agree that I have received, have read, and understand the Addendum, US DOT 49 CFR PART 382 SUBPART G - THE CLEARINGHOUSE ("Addendum") and agree to abide by the terms and conditions of the Addendum.

I understand and agree that my compliance with the terms and conditions of the Addendum form part of my essential job functions and that the terms of the Addendum have been properly mandated by the Company for my own safety, that of my co-workers, as well as of the general public.

I understand and agree that my compliance with the Addendum is an essential and required term of my new or continuing contract of employment or contract for services with the Company. I further understand and agree that, as applicable: (a) my offer of a contract of employment or contract for services with the Company is conditional upon my signing of this Acknowledgement; or (b) the continuation of my contract of employment or contract for services with the Company is conditional upon my signing of this Acknowledgement, and that any failure to sign will result in the immediate termination of my contract.

DATE Signature (Full Name)