Application for Employment

* indicates REQUIRED field

First Name:	*
Last Name:	*
Email:	*
Address:	*
City:	*
State:	*
Zip:	*
Phone:	*
Mobile Phone:
Social Sec. #:	*
Date of Birth:	- -
Salary Desired:
Willing to work 6 days a week?:
	Yes No

Experience and Qualifications - Drivers Licenses
State: License No. Type: Exp Date:
State: License No. Type: Exp Date:
State: License No. Type: Exp Date:

Experience and Qualifications - Driving Experience
Straight Truck:
Type: From Date: To Date: # Miles:
Tractor & Semi-Trailer:
Type: From Date: To Date: # Miles:
Dump Truck:
Type: From Date: To Date: # Miles:
Other:
Type: From Date: To Date: # Miles:

Experience and Qualifications - Accident Record (past 3 years or more)
Last Accident:
Nature: Fatalities: Injuries:
Next Previous:
Nature: Fatalities: Injuries:
Next Previous:
Nature: Fatalities Injuries:

Traffic Convictions and Forfeitures for the past 3 years or more (other than parking violations)
Location: Date: Charge: Penalty:
Location: Date: Charge: Penalty:
Location: Date: Charge: Penalty:


Have you ever been denied a license, permit or privilege to operate a motor vehicle?:
	No Yes
Has any license, permit or privilege ever been suspended or revoked?:
	No Yes
If you answered Yes to either of the above questions, please explain:


Employment History - Last Employer
Note: DOT requires that empolyment for the past 3 years and/or commercial driving experience for the past 10 years be shown.
Last Employer:
Full Address:
Position Held:
Dates Employed:	From: To:
Salary:
Reason for Leaving:

Employment History - Second Last Employer
Last Employer:
Full Address:
Position Held:
Dates Employed:	From: To:
Salary:
Reason for Leaving:

Employment History - Third Last Employer
Third Last Employer:
Full Address:
Position Held:
Dates Employed:	From: To:
Salary:
Reason for Leaving:

Please list the types of dumptrucks and/or equipment you have operated in the past with years experience for each type:


Driver Position Applicant Agreement By submitting this form you agree to the following: In the event Jimmy Richards & Sons Exc., Inc. hires you for a Driver position it will be your responsibility to pay for the Pre-Employment Drug Screening. I agree *