J.P. Transport Inc.
2721 W. State Route 161
Columbus, Ohio 43235

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.

TO BE READ AND ELECTRONICALLY SIGNED BY APPLICANT

I 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 and 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 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.

Please provide your electronic signature by typing your name here:
Date:

APPLICANT TO COMPLETE
(answer all questions)

Position Applied for: Delivery Driver (All Classes)
Name
First
Middle
Last		 Social Security Number
How did you hear about us?
List your addresses of residency for the past 3 years.
Current Address

 

 

Previous
Addresses      


Street
City

State
Zip Code		 Phone How Long?
yr./mo.

Street
City
State & Zip Code		 How Long?
yr./mo.

Street
City
State & Zip Code		 How Long?
yr./mo.

Street
City
State & Zip Code		 How Long?
yr./mo.
Do you have the legal right to work in the United States?

Date of Birth // Can you provide proof of age?
(Required for Commercial Drivers)

Have you worked for this company before? Where?

Dates: From To 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 below. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.

Is there any reason why you might be unable to perform the functions of the job for which you have applied [as described here]

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. Please email our Personnel Manager if additional information is necessary).

EMPLOYER
DATE
NAME FROM
MO./YR. 		TO
MO./YR.
ADDRESS POSITION HELD
CITY STATE
ZIP 		SALARY/WAGE
CONTACT PERSON
PHONE NUMBER 		REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs** WHILE EMPLOYED?
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?

EMPLOYER
DATE
NAME FROM
MO./YR. 		TO
MO./YR.
ADDRESS POSITION HELD
CITY STATE
ZIP 		SALARY/WAGE
CONTACT PERSON
PHONE NUMBER 		REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs** WHILE EMPLOYED?
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?

EMPLOYER
DATE
NAME FROM
MO./YR. 		TO
MO./YR.
ADDRESS POSITION HELD
CITY STATE
ZIP 		SALARY/WAGE
CONTACT PERSON
PHONE NUMBER 		REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs** WHILE EMPLOYED?
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?

EMPLOYER
DATE
NAME FROM
MO./YR. 		TO
MO./YR.
ADDRESS POSITION HELD
CITY STATE
ZIP 		SALARY/WAGE
CONTACT PERSON
PHONE NUMBER 		REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs** WHILE EMPLOYED?
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?

EMPLOYER
DATE
NAME FROM
MO./YR. 		TO
MO./YR.
ADDRESS POSITION HELD
CITY STATE
ZIP 		SALARY/WAGE
CONTACT PERSON
PHONE NUMBER 		REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs** WHILE EMPLOYED?
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?

EMPLOYER
DATE
NAME FROM
MO./YR. 		TO
MO./YR.
ADDRESS POSITION HELD
CITY STATE
ZIP 		SALARY/WAGE
CONTACT PERSON
PHONE NUMBER 		REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs** WHILE EMPLOYED?
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?

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (Please email our Personnel Manager if additional information is necessary). IF NONE, WRITE NONE

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

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

LOCATION DATE CHARGE PENALTY

Please email our Personnel Manager if additional space is needed.

EXPERIENCE AND QUALIFICATIONS — DRIVER
List all driver licenses or permits within the last 3 years:

DRIVER
    LICENSES		 STATE LICENSE NO. TYPE EXPIRATION DATE

  1. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
  2. Has any license, permit or privilege ever been suspended or revoked?
IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS

DRIVING EXPERIENCE: SELECT YES OR NO
CLASS OF EQUIPMENT TYPE OF EQUIPMENT DATES FROM (M/Y) TO (M/Y) APPROX. NO. OF MILES (TOTAL)
STRAIGHT TRUCK
TRAILER AND SEMI-TRAILER
TRACTOR – TWO TRAILERS
TRACTOR – THREE TRAILERS
MOTORCOACH – SCHOOL BUS

More than 8 passengers
MOTORCOACH – SCHOOL BUS

More than 15 passengers
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)

EDUCATION

HIGHEST GRADE COMPLETED:

HIGH SCHOOL: COLLEGE:

LAST SCHOOL ATTENDED (Name)

(City, State)

DATE AND SIGNATURE:

To be considered for employment, you must provide your electronic signature below.
All answers and statements are true and complete to the best of my knowledge. I understand that J.P. Transport, Inc. may verify information, and that untruthful or misleading answers are cause for rejection of this application or dismissal if employed.
Check this box to certify that you have read and accepted the above statement.
Date:   Name:

Number of Weekly Hours Requested:
Name: Available Start Date (very important):
P = PREFERRED SCHEDULE
UA = UNAVAILABLE
NP = NOT PREFERRED, BUT AVAILABLE
 MondayTuesday Wednesday Thursday Friday Saturday Sunday
6:00 – 7:00
AM
7:00 – 8:00
AM
8:00 – 9:00
AM
9:00 – 10:00
AM
10:00 – 11:00
AM
11:00 – 12:00
NOON
12:00 – 1:00
PM
1:00 – 2:00
PM
2:00 – 3:00
PM
3:00 – 4:00
PM
4:00 – 5:00
PM
5:00 – 6:00
PM
6:00 – 7:00
PM
7:00 – 8:00
PM
8:00 – 9:00
PM

                                 

Copyright © 2006, Mr. Mulch, Inc. • All Rights Reserved. • Contact Our Webmaster