Job Application

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*Full Name: Date: Month/ Day/ Year

*Address: City: State: Zip:

*Home Phone #: Cell Phone:

*Email Address:

Previous Address: City: State: Zip:

S.S. #: Drivers License Number: State:
Class of License:

Exp Date:
Birth Date:
Sex:
Ht:
Wt:

Position Applying For?
How many years verifiable experience do you have driving tractor/trailer?
How many years experience do you have driving tractor/trailer over the road?

List all drivers' licenses in your possession or held in the last three years:
State License # Class Expiration Date
1.
2.
3.

List Special Courses, Training, schools (including dates) you have attended:

Accident Record: (List All Accidents During Past 3 Years)
(Omissions in this section will be considered as falsifications & will result in disqualification)
Date of Accident Nature of Accident Fatalities? Injuries? At Fault?
1.
2.

Traffic Record: (List All Traffic Citations and Infractions for Past 3 Years)
(Omissions in this section will be considered as falsifications & will result in disqualification)
Date Location Charge Penalty Vehicle Type
1.
2.
3.

Former Employment: (Show all employment for past 10 years, include all breaks in employment and explain why, below. Be Complete and accurate Applications missing information will not be processed.)
Most Recent Employer Address City State DOT Regulated?
Dates Worked (from/To) Phone Number Position Reason You Left?


Previous Employer Address City State DOT Regulated?
Dates Worked (from/To) Phone Number Position Reason You Left?


Previous Employer Address City State DOT Regulated?
Dates Worked (from/To) Phone Number Position Reason You Left?


Previous Employer Address City State DOT Regulated?
Dates Worked (from/To) Phone Number Position Reason You Left?


Previous Employer Address City State DOT Regulated?
Dates Worked (from/To) Phone Number Position Reason You Left?


Previous Employer Address City State DOT Regulated?
Dates Worked (from/To) Phone Number Position Reason You Left?

If you had breaks in your employment explain why here:

Education: High School: City: State:
Last Grade Completed: Year Graduated:
College Attended: Degree Earned:

Military Experience:(Please list all military experience including dates, rank, discharge status)

Personal References:(Please list 3 personal references, Include name, Phone# and relationship)

Physical History: Date of last Physical Doctor
Are you Physically capable of heavy manual work?
Are you Physically capable of lifting 42 lbs. over head and 75 lbs. to waist level?
Are you using a controlled substance legally prescribed by a medical practitioner?
If yes, do you have a release from your medical practitioner to operate heavy equipment and/or drive a tractor trailer while taking the substance?

The Following questions MUST be answered to be considered for employment:

Has any license, permit, or driving privlege ever been suspended or revoked?
If yes please explain and give date of occurrence, below.

Have you ever been convicted, or forfeited a bond, for driving while under the influence of drugs or alcohol? If Yes, When Where
Do you read, write, speak and understand the English language fluently?
Have you ever tested positive for a controlled substance? When?
Have you ever been known by another name other than the one on this application? If yes, what name?
Emergency Contact Phone # Relationship

Who Referred you?

Applicant for position that require driving a commercial vehicle (CMV) at anytime will be required to undergo controlled substances testing and at our discretion, alcohol testing prior to employment. They will also be subject to further testing throughout their period of employment, as per FMCSA and company policy. Applicants will also be asked to sign forms for release of information from previous employers in all cases where driving a CMV was one of their functions. Failure to sign will prevent James H. Clark & Son, Inc. from using them as CMV driver, as per FMCSA and company policy.

I certify 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. It is agreed and understood by me that any misrepresentation of information given shall b e considered as falsification and grounds for immediate disqualification. It is agreed and understood by me that James H. Clark & Son, Inc. or it's agents may investigate my background to ascertain any and all information of concern to my record, whether same is of record or not. I release James H. Clark & Son, Inc., its agents, & all persons and companies named herein form all liability for any and all damages on account of their furnishing such information. It is understood that as part of the background check that former employers will be asked to disclose all work related history as well as any drug and alcohol test results and/or alcohol while in their employ. I hereby release all companies and their agents from all liability resulting from the release of information concerning drug & alcohol testing, problems, refusal to test treatment programs prescribed, etc.

I agree to furnish such additional information and complete such examinations as may be required to complete this qualification file. I is agreed and understood by me that this application for qualification in no way obligates James H. Clark & Son, Inc. to employ me. If requested to do so, I agree to submit to physical and/or psychological testing, including but not limited to analysis and testing for alcohol. I understand that the information in this application will be used, and that previous employers will be contacted, for purposes of investigation as required by FMCSR Part 391.23. I understand that I am not a James H. Clark & Son, Inc. terminal in Murray, Utah and pass a DOT pre-employment drug screen, pass a road test administered by James H. Clark & Son, Inc. and satisfactorily complete the James H. Clark Son, Inc. orientation.

Digital Signature Date: Month/ Day/ Year
(Please type your full name)