Application for Employment - Northwest Total Site

Application for Employment - Northwest Asphalt, Inc 1451 Stagecoach Road, Shakopee, MN 55379

This employer requires a pre-employment drug test. 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, or non job related disability.

Name *

Position(s) Applied for:

Date of Application *

Email Address

Phone Number *

Alternate Phone Number

Who Referred You?

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

How long have you resided at your current address? *

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

YES
NO

Have you worked for this company before? *

YES
NO

If yes, please enter the begining and ending dates and reason(s) for leaving.

Previous Address

Address Line 1

Address Line 2

City

State

Zip Code

How long did you reside at your previous address?

Are you currently employed? *

YES
NO

Is there any reason you might be unable to perform the functions of the job for which you have applied? *

YES
NO

If yes, please describe.

Employment History

Please begin with most present/last job. All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding three years. Applicants to drive a commercial motor vehicle (Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding) in intrastate or interstate commerce shall also provide an additional seven years' information on those employers for whom the applicant operated such vehicle. Please attach a .pdf for more history if necessary.

Employer #1

Address #1

Address Line 1

Address Line 2

City

State

Zip Code

Employer #1 Phone

Phone

Position #1

Position

Job Duties #1

Brief Description of Job Duties

Reason for Leaving #1

Reason for Leaving

Starting Date #1

Starting Date

Ending Date #1

Ending Date

Employer #1 Contact Name

Contact Name

Employer #1 Contact Phone

Contact Phone Number

Employer #1 Contact YES/NO

YES
NO

May we contact your previous Employer?

Employer #1 Federal Motor Carrier Safety

YES
NO

While employed here, were you subject to the Federal Motor Carrier Saftey Regulations?

Employer #1 Alcohol and Controlled Substances Testing

YES
NO

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CRP, part 40?

Employer #2

Address #2

Address Line 1

Address Line 2

City

State

Zip Code

Employer #2 Phone

Phone

Position #2

Position

Job Duties #2

Brief Description of Job Duties

Reason for Leaving #2

Reason for Leaving

Starting Date #2

Starting Date

Ending Date #2

Ending Date

Employer #2 Contact Name

Contact Name

Employer #2 Contact Phone

Contact Phone Number

Employer #2 Contact YES/NO

YES
NO

May we contact your previous Employer?

Employer #2 Federal Motor Carrier Safety

YES
NO

While employed here, were you subject to the Federal Motor Carrier Saftey Regulations?

Employer #2 Alcohol and Controlled Substances Testing

YES
NO

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CRP, part 40?

Employer #3

Address #3

Address Line 1

Address Line 2

City

State

Zip Code

Employer #3

Phone

Position #3

Position

Job Duties #3

Brief Description of Job Duties

Reason for Leaving #3

Reason for Leaving

Starting Date #3

Starting Date

Ending Date #3

Ending Date

Employer #3 Contact Name

Contact Name

Employer #3 Contact Phone

Contact Phone Number

Employer #3 Contact YES/NO

YES
NO

May we contact your previous Employer?

Employer #3 Federal Motor Carrier Safety

YES
NO

While employed here, were you subject to the Federal Motor Carrier Saftey Regulations?

Employer #3 Alcohol and Controlled Substances Testing

YES
NO

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CRP, part 40?

Experience and Qualifications

Experience

Please show any trucking, transportation or other experience that may help in your work for this company.

Training

Please list courses and training that may help in your work for this company.

Special Equipment or Technical Materials

Please list special equipment and/or technical materials you can work with.

Driving Record and Experience

If you will EVER be operating a Company Vehicle here at NWA, please complete the following section. If not, skip to references.

Current Driver's License Information

Please list State Issued Driver's License Type, Licenses Number, Expiration date and which State Issued.

Endorsements

Please list any endorsements you have including tanker and Hazmat.

States Operated

Please list the states in which you have operated for the last five years.

Safe Driving Awards

Please list which safe driving awards you hold and from whom.

Denied, Suspended, Revoked

Please explain if you have ever been denied a license, permit or privlege to operate a motor vehicle and/or if your license, permit or privilege has ever been suspended or revoked.

Equipment

Please list any experience in the following classes of equipment. List the type (van, tank, flat, etc) for each. Also include the dates in which operated them and the approximate number of miles driven. List any other equipment here:

Other

Straight Truck

Type, Dates Operated To/From, and approx. miles.

Motorcoach/Schoolbus

Type, Dates Operated To/From, and approx. miles.

Tractor and Semi Trailer

Type, Dates Operated To/From, and approx. miles.

Tractor & Two Trailers

Type, Dates Operated To/From, and approx. miles.

Accident Record

Please list any accidents for the past 3 years. Please attach .pdf for more history if necessary.

Accident in the past 3 years. *

YES
NO
YES, MORE THAN 3

Date of Accident #1

Date

Date of Accident #2

Date

Date of Accident #3

Date

Nature of Accident #1

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

Nature of Accident #2

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

Nature of Accident #3

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

Fatalties/Injuries of Accident #1

Please list any injuries or fatalities.

Fatalties/Injuries of Accident #2

Please list any injuries or fatalities.

Fatalties/Injuries of Accident #3

Please list any injuries or fatalities.

Traffic Convictions and Forfeitures

Please list any traffic convictions and forfeitures (other than parking violations) for the past 3 years. Please attach .pdf for more history if necessary.

Traffic Conviction/Forfeiture in the past 3 years. *

YES
NO
YES, MORE THAN 3

Date of Traffic #1

Date

Date of Traffic #2

Date

Date of Traffic #3

Date

Location of Traffic #1

Location

Location of Traffic #2

Location

Location of Traffic #2

Location

Traffic Charge #1

Charge

Traffic Charge #2

Charge

Traffic Charge #3

Charge

Traffic Penalty #1

Please list any penalties associated.

Traffic Penalty #2

Please list any penalties associated.

Traffic Penalty #3

Please list any penalties associated.

References

Please list the name, address and phone number and years you have known your reference.

Reference #1

Reference #2

Reference #3

Please attach your Resume or CV and additional history if neccesary.

Click or drag a file to this area to upload.

Please upload in .pdf format only.

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. I authorize you to make such investigations and inquires 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 inquires and releasing information in connection with my application. In the event of employment, I understand that false or misleading information giving 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.

Signature *

Clear Signature

Drug Test *

This employer requires a pre-employment drug test. Please check this box to confirm you have read this section. *

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, or non job related disability.

MVR Release Consent Form

This consent is given in satisfaction of Public Law 18 USC 2721 et. Seq.. "Federal Drivers Privacy Protection Act", and is intended to constitute "written consent" as required by this Act.

In conjunction with my employment, at Northwest Asphalt Inc. ("the company"), I consent to the release of my Motor Vehicle Record (MVR) to the company. I understand the company will use these records to evaluate my suitability to fulfill driving duties that may be related to the position for which I am applying. I also consent to the review, evaluation, and other use of any MVR I may have provided to the company.

MVR - Name

Applicant Name

MVR - Date of Birth

Date of Birth

MVR - Driver's License Number

Driver's License Number

MVR - Driver's License State

Driver's License Issuing State

MVR - Driver's License Expiration Date

Driver's License Expiration Date

Signature

Clear Signature