Auxier Gas | Employment Application

Employment Application

Position(s) Applied For: Position(s) Applied For:

First Name: First Name:

Last Name: Last Name:

Middle Name: Middle Name:

List your addresses of residency for the past 3 years.

Current Address

Street: Street:

City: City:

State:

ZIP Code: ZIP Code:

Phone: Phone

How Long?: How Long?:

Previous Addresses

Street: Street:

City: City:

State:

ZIP Code: ZIP Code:

How Long?: How Long?:

Street: Street:

City: City:

State:

ZIP Code: ZIP Code:

How Long?: How Long?:

Street: Street:

City: City:

State:

ZIP Code: ZIP Code:

How Long?: How Long?:

Do you have the legal right to work in the United States?: Do you have the legal right to work in the United States?:

Date of Birth: Date of Birth

Can you provide proof of age?: Can you provide proof of age?:

Have you worked for this company before?: Have you worked for this company before?:

Where?: Where?:

From:: From:

To:: To:

Rate of Pay: Rate of Pay:

Position: Position:

Reason for Leaving: Reason for Leaving

Are you now employed?: Are you now employed?:

If not, how long since leaving last employment?: If not, how long since leaving last employment?:

Who referred you?: Who referred you?:

Rate of pay expected: Rate of pay expected:

Have you ever been bonded?: Have you ever been bonded?:

Name of bonding company: Name of bonding company:

Have you ever been convicted of a felony?: Have you ever been convicted of a felony?:

If yes, please explain. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.: If yes, please explain. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.

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]?: 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]?

If yes, explain if you wish.: 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.)

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

Name: Name:

From:: From:

To:: To:

Position Held: Position Held:

Address: Address:

City: City:

State:

ZIP: ZIP:

Salary/Wage: Salary/Wage:

Contact Person: Contact Person:

Phone Number: Phone Number

Reason for Leaving: Reason for Leaving

Were You Subject to FMCSRs While Employed?

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

n/a yes no

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? 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?: n/a yes no

Name: Name:

From:: From:

To:: To:

Position Held: Position Held:

Address: Address:

City: City:

State:

ZIP: ZIP:

Salary/Wage: Salary/Wage:

Contact Person: Contact Person:

Phone Number: Phone Number

Reason for Leaving: Reason for Leaving

Were You Subject to FMCSRs While Employed? Were You Subject to FMCSRs While Employed?: n/a yes no

Name: Name:

From:: From:

To:: To:

Position Held: Position Held:

Address: Address:

City: City:

State:

ZIP: ZIP:

Salary/Wage: Salary/Wage:

Contact Person: Contact Person:

Phone Number: Phone Number

Reason for Leaving: Reason for Leaving

Were You Subject to FMCSRs While Employed? Were You Subject to FMCSRs While Employed?: n/a yes no

Name: Name:

From:: From:

To:: To:

Position Held: Position Held:

Address: Address:

City: City:

State:

ZIP: ZIP:

Salary/Wage: Salary/Wage:

Contact Person: Contact Person:

Phone Number: Phone Number

Reason for Leaving: Reason for Leaving

Were You Subject to FMCSRs While Employed? Were You Subject to FMCSRs While Employed?: n/a yes no

Name: Name:

From:: From:

To:: To:

Position Held: Position Held:

Address: Address:

City: City:

State:

ZIP: ZIP:

Salary/Wage: Salary/Wage:

Contact Person: Contact Person:

Phone Number: Phone Number

Reason for Leaving: Reason for Leaving

Were You Subject to FMCSRs While Employed? Were You Subject to FMCSRs While Employed?: n/a yes no

Name: Name:

From:: From:

To:: To:

Position Held: Position Held:

Address: Address:

City: City:

State:

ZIP: ZIP:

Salary/Wage: Salary/Wage:

Contact Person: Contact Person:

Phone Number: Phone Number

Reason for Leaving: Reason for Leaving

Were You Subject to FMCSRs While Employed? Were You Subject to FMCSRs While Employed?: n/a yes no

Additional Information, If Necessary: Additional Information, If Necessary

Accident Record For the Past 3 Years or More (If None, Write None)

Last Accident: Last Accident

Nature of Accident (Head-On, Rear-End, Upset, etc.): Nature of Accident (Head-On, Rear-End, Upset, etc.):

Fatalities: Fatalities:

Injuries: Injuries:

Hazardous Material Spill: Hazardous Material Spill:

Next Previous: Next Previous

Nature of Accident (Head-On, Rear-End, Upset, etc.): Nature of Accident (Head-On, Rear-End, Upset, etc.):

Fatalities: Fatalities:

Injuries: Injuries:

Hazardous Material Spill: Hazardous Material Spill:

Next Previous: Next Previous

Nature of Accident (Head-On, Rear-End, Upset, etc.): Nature of Accident (Head-On, Rear-End, Upset, etc.):

Fatalities: Fatalities:

Injuries: Injuries:

Hazardous Material Spill: Hazardous Material Spill:

Additional Information, If Necessary: Additional Information, If Necessary

Traffic Convictions and Forfeitures for the Past 3 Years (Other than Parking Violations) If None, Write None

Location: Location:

Date: Date

Charge: Charge:

Penalty: Penalty:

Location 2: Location 2:

Date: Date

Charge: Charge:

Penalty: Penalty:

Location 3: Location 3:

Date: Date

Charge: Charge:

Penalty: Penalty:

Additional Information, If Necessary: Additional Information, If Necessary

Experience and Qualifications - Driver

List All Driver Licenses or Permits Held in the Past 3 Years

State:

License No.: License No.:

Type: Type:

Expiration Date: Expiration Date

State:

License No. 2: License No. 2:

Type: Type:

Expiration Date: Expiration Date

State:

License No. 3: License No. 3:

Type: Type:

Expiration Date: Expiration Date

Additional Information, If Necessary: Additional Information, If Necessary

A. Have You Ever Been Denied a License, Permit, or Privilage to Operate a Motor Vehicle? A. Have You Ever Been Denied a License, Permit, or Privilage to Operate a Motor Vehicle?: yes no

B. Has Any License, Permit, or Privilege Ever Been Suspended or Revoked? B. Has Any License, Permit, or Privilege Ever Been Suspended or Revoked?: yes no

If the Answer to Either A or B Is Yes, Give Details: If the Answer to Either A or B Is Yes, Give Details

Driving Experience

Straight Truck Straight Truck: yes no

Type of Equipment Type of Equipment: van tank flat dump refer

From:: From:

To:: To:

Approx. Number of Miles (Total): Approx. Number of Miles (Total):

Tractor and Semi-Trailer Tractor and Semi-Trailer: yes no

Type of Equipment Type of Equipment: van tank flat dump refer

From:: From:

To:: To:

Approx. Number of Miles (Total): Approx. Number of Miles (Total):

Tractor - Two Trailers Tractor - Two Trailers: yes no

Type of Equipment Type of Equipment: van tank flat dump refer

From:: From:

To:: To:

Approx. Number of Miles (Total): Approx. Number of Miles (Total):

Tractor - Three Trailers Tractor - Three Trailers: yes no

Type of Equipment Type of Equipment: van tank flat dump refer

From:: From:

To:: To:

Approx. Number of Miles (Total): Approx. Number of Miles (Total):

Motorcoach - School Bus (More than 8 passengers) Motorcoach - School Bus (More than 8 passengers): yes no

From:: From:

To:: To:

Approx. Number of Miles (Total): Approx. Number of Miles (Total):

Motorcoach - School Bus (More than 15 passengers) Motorcoach - School Bus (More than 15 passengers): yes no

From:: From:

To:: To:

Approx. Number of Miles (Total): Approx. Number of Miles (Total):

Other: Other

List States Operated in for Last Five Years: List States Operated in for Last Five Years

Show Special Courses or Training that will Help You as a Driver: Show Special Courses or Training that will Help You as a Driver

Which Safe Driving Awards Do You Hold and From Whom?: 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: 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 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): List Special Equipment or Technical Materials You Can Work With (Other than Those Already Shown)

Education

Last School Attended Name: Last School Attended Name:

City: City:

State:

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.

Signature: Signature:

Date: Date