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Employment Application

PLEASE READ CAREFULLY
Note: Fields marked with a * require an answer. Please use "N/A" for "not applicable" if necessary. Applicants may be required to complete and sign a paper application for employment upon interview.

Pre-Employment Agreement

All job applicants at Ameri-Tex Services, Inc. will undergo screening for the presence of illegal or non-prescribed medication as a condition of employment.

Applicants will be required to submit to a urinalysis test at a laboratory chosen by the company. By signing the pre-employment agreement, the job applicant consents to the urinalysis and therefore releases the company of any liability. The job applicant will pay for the pre-employment drug screen and upon negative results will be reimbursed by Ameri-Tex Services, Inc. Any applicant with positive test results will be denied employment at that time.

The company will not discriminate against applicants for employment because of past drug or alcohol abuse. It is the current abuse of drugs, alcohol, or non-prescribed medication that the company will not tolerate.

I agree to submit to a urinalysis (drug screen) as part of my application for employment. I understand that either refusal to submit to the urinalysis screen or failure to qualify according to the minimum standards established by the company for this screen might disqualify me from further consideration for employment.

I further understand that upon commencement of employment with the company, I may again be required to submit to a random or reasonable suspicion urinalysis screen. I understand that refusal to take a requested urinalysis screen or failure to meet the minimum standards set for the screen may result in immediate suspension or termination.

In the event that employment commences prior to the employer receiving the drug test results, I understand that I will be immediately discharged if the result comes back positive.

I understand that in case of an accident while driving a company vehicle I will immediately be tested also.

I acknowledge that as a condition of pre-employment I am required to pay for the initial urinalysis. Upon the result of a negative drug screen I will be reimbursed by Ameri-Tex Services, Inc. on the second full paycheck I receive. I must provide a receipt of payment from DATCS in order or be reimbursed accordingly. In the event of a positive drug screen, I will be denied employment.

I have read in full and understand the above statements and conditions of employment.


Attach Resume:
Attach Health Card:
Attach Driver's License:
*Email:
Applying for:

Applicant Information

*First Name: *Last Name:
MI:
*Address: Apartment/Unit #
*City *State
*Zip
*Phone: Referred By:
Date Available:

Salary Expected:
I can work:  Weekends    Evening    Night
U.S. Citizen:    Yes    No If not, are you authorized to work in the U.S.?:  Yes     No
Languages Spoken:
*Have you ever worked for this company?:  Yes     No
If yes, when?: ------ To ------
*Have you ever been convicted of a felony?
(By company policy some misdemeanors may bar employment):
 Yes     No
If yes, explain briefly:

Education

High School:   Address:
Graduate:    Yes     No   Degree:
College:   Address:
Graduate:    Yes     No   Degree:
Other:   Address:
Graduate:    Yes     No   Degree:

References

Please list three references not related to you, whom you have known at least one year.
Name: Occupation:
Company: Day Phone Numbers:
Address:
Name: Occupation:
Company: Day Phone Numbers:
Address:
Name: Occupation:
Company: Day Phone Numbers:
Address:

Employment History

Previous 10 years employment required for CDL drivers
Company Name: Complete Address
(w/ City, State, Zip):
Phone: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
Start Date:
(mm/dd/yyyy)
  End Date:
(mm/dd/yyyy)
 
Reason for Leaving: May we contact your previous employer for a reference?  Yes    No


Accident Record and Traffic Convictions

Include vehicles having a GVWR of 26,001 lbs. or more (or 10,000 lb. for interstate), 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. If none, write "none".

Dates Type of Vehicle Nature of Accident (Head-On, Rear-End, Upset, Etc.) Fatalities Injuries

List all violations of motor vehicle laws or ordinances (other than parking violations) of which you were convicted, forfeited bond, or collateral during the past three (3) years.

Location Date Charge Penalty

Experience and Qualifications - Driver

Driver's Licenses
State License No. Type Expiration Date

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?  Yes    No
Has any license, permit, or privilege ever been suspended or revoked?  Yes    No
Include a detailed explanation of the facts and circumstances for each denial, revocation, or suspension.

Driving Experience (If None, Write "None")

Class of Equipment Type of Equipment (Van, Tank, Flat, Etc.) Date From Date To Approx No. of Miles (Total)
Straight Truck
Tractor & Semi-Trailer
Tractor - Two Trailers
Motor coach - 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 those shown elsewhere in this application.
List special equipment or technical materials you can work with (other than those already shown).

DRUG TESTING 49 CFR 40.2S(j)

Have you ever tested positive or refused to test on any pre-employment drug or alcohol test administered by an employer to which you have applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?  Yes    No
If YES --- Have you successfully completed the return to duty process?  Yes    No
If YES --- Documentation MUST BE PROVIDED before any safety-sensitive transportation function is performed.  Yes    No
If yes, please give details.

Complete the following information only if applying for a position that requires use of a vehicle while conducting company business. If hired, your information will be verified with a Motor Vehicle Report.
How many traffic violations have you had during the last two years?
Driver's License Number: State:

Applicant's Statement

Notification and Agreement

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 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 Ameri-Tex Services, Inc

MOTOR VEHICLE REPORT DISCLOSURE & AUTHORIZATION TO RELEASE INFORMATION I am aware that a consumer report, (motor vehicle record) will be obtained on me in the course of consideration for employment and at any time throughout my employment.

Any documents/records obtained pursuant to this authorization may be disclosed to any insurance carrier or prospective insurance carrier of the entity to which I am applying for employment and/or to whom I am currently employed. I understand that this may result in that insurance entity obtaining motor vehicle/driver history information on me.

By signing this application, I hereby authorize, without reservation, any party, state, or agency contacted by Ameri-Tex Services, Inc. to furnish the above mentioned information.

By signing this application, I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

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.