{"id":432,"date":"2025-06-30T11:04:34","date_gmt":"2025-06-30T17:04:34","guid":{"rendered":"https:\/\/www.northwest-totalsite.com\/wp\/?page_id=432"},"modified":"2025-06-30T11:04:35","modified_gmt":"2025-06-30T17:04:35","slug":"application-for-employment","status":"publish","type":"page","link":"https:\/\/www.northwest-totalsite.com\/wp\/?page_id=432","title":{"rendered":"Application for Employment"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-container-save-resume\" id=\"wpforms-416\"><form id=\"wpforms-form-416\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"416\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wp\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F432&#038;wpforms_form_id=416\" data-token=\"dbec7c3bba81723c2d8e441ea383bf7a\" data-token-time=\"1776969467\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-416-field_174-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"174\"><h3 id=\"wpforms-416-field_174\">Application for Employment - Northwest Asphalt, Inc 1451 Stagecoach Road, Shakopee, MN 55379<\/h3><div class=\"wpforms-field-description\">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.<\/div><\/div><div id=\"wpforms-416-field_9-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"9\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-416-field_43-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_43\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-416-field_43\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][43]\" required><\/div><div id=\"wpforms-416-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_5\">Position(s) Applied for:<\/label><input type=\"text\" id=\"wpforms-416-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-416-field_6-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_6\">Date of Application <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_6\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][6][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-416-field_42-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_42\">Email Address<\/label><input type=\"email\" id=\"wpforms-416-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" spellcheck=\"false\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_10-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"10\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_15-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_15\">Phone Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-416-field_15\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][15]\" aria-label=\"Phone Number\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_16-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_16\">Alternate Phone Number<\/label><input type=\"tel\" id=\"wpforms-416-field_16\" class=\"wpforms-field-medium wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][16]\" aria-label=\"Alternate Phone Number\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_17\">Who Referred You?<\/label><input type=\"text\" id=\"wpforms-416-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_19-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"19\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-416-field_20-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"20\"><label class=\"wpforms-field-label\">Current Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-416-field_20\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][20][address1]\" required><label for=\"wpforms-416-field_20\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-416-field_20-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][20][address2]\" ><label for=\"wpforms-416-field_20-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-416-field_20-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][20][city]\" required><label for=\"wpforms-416-field_20-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-416-field_20-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][20][state]\" required><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\"  selected='selected'>Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-416-field_20-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-416-field_20-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][20][postal]\" required><label for=\"wpforms-416-field_20-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-416-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_22\">How long have you resided at your current address? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-416-field_22\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][22]\" required><\/div><div id=\"wpforms-416-field_37-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"37\"><label class=\"wpforms-field-label\">Do you have the legal right to work in the United States? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-416-field_37\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_37_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"YES\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_37_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_37_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"NO\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_37_2\">NO<\/label><\/li><\/ul><\/div><div id=\"wpforms-416-field_39-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"39\"><label class=\"wpforms-field-label\">Have you worked for this company before? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-416-field_39\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_39_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][39][]\" value=\"YES\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_39_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_39_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][39][]\" value=\"NO\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_39_2\">NO<\/label><\/li><\/ul><\/div><div id=\"wpforms-416-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_29\">If yes, please enter the begining and ending dates and reason(s) for leaving.<\/label><input type=\"text\" id=\"wpforms-416-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-416-field_21-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"21\"><label class=\"wpforms-field-label\">Previous Address<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-416-field_21\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][21][address1]\" ><label for=\"wpforms-416-field_21\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-416-field_21-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][21][address2]\" ><label for=\"wpforms-416-field_21-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-416-field_21-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][21][city]\" ><label for=\"wpforms-416-field_21-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-416-field_21-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][21][state]\" ><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\"  selected='selected'>Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-416-field_21-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-416-field_21-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][21][postal]\" ><label for=\"wpforms-416-field_21-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-416-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_23\">How long did you reside at your previous address?<\/label><input type=\"text\" id=\"wpforms-416-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" ><\/div><div id=\"wpforms-416-field_38-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"38\"><label class=\"wpforms-field-label\">Are you currently employed? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-416-field_38\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_38_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][38][]\" value=\"YES\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_38_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_38_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][38][]\" value=\"NO\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_38_2\">NO<\/label><\/li><\/ul><\/div><div id=\"wpforms-416-field_41-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"41\"><label class=\"wpforms-field-label\">Is there any reason you might be unable to perform the functions of the job for which you have applied? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-416-field_41\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_41_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][41][]\" value=\"YES\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_41_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_41_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][41][]\" value=\"NO\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_41_2\">NO<\/label><\/li><\/ul><\/div><div id=\"wpforms-416-field_33-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_33\">If yes, please describe.<\/label><input type=\"text\" id=\"wpforms-416-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_66-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"66\"><h3 id=\"wpforms-416-field_66\">Employment History<\/h3><div class=\"wpforms-field-description\">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. <\/div><\/div><div id=\"wpforms-416-field_175-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"175\"><h3 id=\"wpforms-416-field_175\">Employer #1<\/h3><\/div><div id=\"wpforms-416-field_44-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"44\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_50-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"50\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_50\">Employer #1<\/label><input type=\"text\" id=\"wpforms-416-field_50\" class=\"wpforms-field-medium\" name=\"wpforms[fields][50]\" ><div class=\"wpforms-field-description\">Employer #1<\/div><\/div><div id=\"wpforms-416-field_49-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"49\"><label class=\"wpforms-field-label wpforms-label-hide\">Address #1<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-416-field_49\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][49][address1]\" ><label for=\"wpforms-416-field_49\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-416-field_49-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][49][address2]\" ><label for=\"wpforms-416-field_49-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-416-field_49-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][49][city]\" ><label for=\"wpforms-416-field_49-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-416-field_49-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][49][state]\" ><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\"  selected='selected'>Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-416-field_49-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-416-field_49-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][49][postal]\" ><label for=\"wpforms-416-field_49-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-416-field_58-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"58\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_58\">Employer #1 Phone<\/label><input type=\"tel\" id=\"wpforms-416-field_58\" class=\"wpforms-field-medium wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][58]\" aria-label=\"Employer #1 Phone\" ><div class=\"wpforms-field-description\">Phone<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_51-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"51\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_51\">Position #1<\/label><input type=\"text\" id=\"wpforms-416-field_51\" class=\"wpforms-field-medium\" name=\"wpforms[fields][51]\" ><div class=\"wpforms-field-description\">Position<\/div><\/div><div id=\"wpforms-416-field_60-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"60\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_60\">Job Duties #1<\/label><textarea id=\"wpforms-416-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\" ><\/textarea><div class=\"wpforms-field-description\">Brief Description of Job Duties<\/div><\/div><div id=\"wpforms-416-field_52-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"52\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_52\">Reason for Leaving #1<\/label><input type=\"text\" id=\"wpforms-416-field_52\" class=\"wpforms-field-medium\" name=\"wpforms[fields][52]\" ><div class=\"wpforms-field-description\">Reason for Leaving<\/div><\/div><div id=\"wpforms-416-field_54-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"54\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_54\">Starting Date #1<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_54\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][54][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Starting Date<\/div><\/div><div id=\"wpforms-416-field_56-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"56\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_56\">Ending Date #1<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_56\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][56][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Ending Date<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_61-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"61\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_61\">Employer #1 Contact Name<\/label><input type=\"text\" id=\"wpforms-416-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\" ><div class=\"wpforms-field-description\">Contact Name<\/div><\/div><div id=\"wpforms-416-field_63-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"63\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_63\">Employer #1 Contact Phone<\/label><input type=\"tel\" id=\"wpforms-416-field_63\" class=\"wpforms-field-medium wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][63]\" aria-label=\"Employer #1 Contact Phone\" ><div class=\"wpforms-field-description\">Contact Phone Number<\/div><\/div><div id=\"wpforms-416-field_65-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"65\"><label class=\"wpforms-field-label wpforms-label-hide\">Employer #1 Contact YES\/NO<\/label><ul id=\"wpforms-416-field_65\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_65_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][65][]\" value=\"YES\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_65_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_65_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][65][]\" value=\"NO\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_65_2\">NO<\/label><\/li><\/ul><div class=\"wpforms-field-description\">May we contact your previous Employer?<\/div><\/div><div id=\"wpforms-416-field_185-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"185\"><label class=\"wpforms-field-label wpforms-label-hide\">Employer #1 Federal Motor Carrier Safety<\/label><ul id=\"wpforms-416-field_185\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_185_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][185][]\" value=\"YES\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_185_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_185_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][185][]\" value=\"NO\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_185_2\">NO<\/label><\/li><\/ul><div class=\"wpforms-field-description\">While employed here, were you subject to the Federal Motor Carrier Saftey Regulations?<\/div><\/div><div id=\"wpforms-416-field_186-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"186\"><label class=\"wpforms-field-label wpforms-label-hide\">Employer #1 Alcohol and Controlled Substances Testing <\/label><ul id=\"wpforms-416-field_186\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_186_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][186][]\" value=\"YES\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_186_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_186_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][186][]\" value=\"NO\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_186_2\">NO<\/label><\/li><\/ul><div class=\"wpforms-field-description\">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?<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_176-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"176\"><h3 id=\"wpforms-416-field_176\">Employer #2<\/h3><\/div><div id=\"wpforms-416-field_70-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"70\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_71-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"71\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_71\">Employer #2<\/label><input type=\"text\" id=\"wpforms-416-field_71\" class=\"wpforms-field-medium\" name=\"wpforms[fields][71]\" ><div class=\"wpforms-field-description\">Employer #2<\/div><\/div><div id=\"wpforms-416-field_73-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"73\"><label class=\"wpforms-field-label wpforms-label-hide\">Address #2<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-416-field_73\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][73][address1]\" ><label for=\"wpforms-416-field_73\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-416-field_73-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][73][address2]\" ><label for=\"wpforms-416-field_73-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-416-field_73-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][73][city]\" ><label for=\"wpforms-416-field_73-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-416-field_73-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][73][state]\" ><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\"  selected='selected'>Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-416-field_73-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-416-field_73-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][73][postal]\" ><label for=\"wpforms-416-field_73-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-416-field_74-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"74\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_74\">Employer #2 Phone <\/label><input type=\"tel\" id=\"wpforms-416-field_74\" class=\"wpforms-field-medium wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][74]\" aria-label=\"Employer #2 Phone \" ><div class=\"wpforms-field-description\">Phone<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_72-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"72\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_72\">Position #2<\/label><input type=\"text\" id=\"wpforms-416-field_72\" class=\"wpforms-field-medium\" name=\"wpforms[fields][72]\" ><div class=\"wpforms-field-description\">Position<\/div><\/div><div id=\"wpforms-416-field_79-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"79\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_79\">Job Duties #2<\/label><textarea id=\"wpforms-416-field_79\" class=\"wpforms-field-medium\" name=\"wpforms[fields][79]\" ><\/textarea><div class=\"wpforms-field-description\">Brief Description of Job Duties<\/div><\/div><div id=\"wpforms-416-field_75-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"75\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_75\">Reason for Leaving #2<\/label><input type=\"text\" id=\"wpforms-416-field_75\" class=\"wpforms-field-medium\" name=\"wpforms[fields][75]\" ><div class=\"wpforms-field-description\">Reason for Leaving<\/div><\/div><div id=\"wpforms-416-field_76-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"76\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_76\">Starting Date #2<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_76\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][76][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Starting Date<\/div><\/div><div id=\"wpforms-416-field_77-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"77\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_77\">Ending Date #2<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_77\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][77][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Ending Date<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_81-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"81\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_81\">Employer #2 Contact Name<\/label><input type=\"text\" id=\"wpforms-416-field_81\" class=\"wpforms-field-medium\" name=\"wpforms[fields][81]\" ><div class=\"wpforms-field-description\">Contact Name<\/div><\/div><div id=\"wpforms-416-field_82-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"82\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_82\">Employer #2 Contact Phone<\/label><input type=\"tel\" id=\"wpforms-416-field_82\" class=\"wpforms-field-medium wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][82]\" aria-label=\"Employer #2 Contact Phone\" ><div class=\"wpforms-field-description\">Contact Phone Number<\/div><\/div><div id=\"wpforms-416-field_80-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"80\"><label class=\"wpforms-field-label wpforms-label-hide\">Employer #2 Contact YES\/NO<\/label><ul id=\"wpforms-416-field_80\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_80_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][80][]\" value=\"YES\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_80_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_80_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][80][]\" value=\"NO\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_80_2\">NO<\/label><\/li><\/ul><div class=\"wpforms-field-description\">May we contact your previous Employer?<\/div><\/div><div id=\"wpforms-416-field_188-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"188\"><label class=\"wpforms-field-label wpforms-label-hide\">Employer #2 Federal Motor Carrier Safety<\/label><ul id=\"wpforms-416-field_188\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_188_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][188][]\" value=\"YES\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_188_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_188_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][188][]\" value=\"NO\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_188_2\">NO<\/label><\/li><\/ul><div class=\"wpforms-field-description\">While employed here, were you subject to the Federal Motor Carrier Saftey Regulations?<\/div><\/div><div id=\"wpforms-416-field_187-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"187\"><label class=\"wpforms-field-label wpforms-label-hide\">Employer #2 Alcohol and Controlled Substances Testing<\/label><ul id=\"wpforms-416-field_187\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_187_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][187][]\" value=\"YES\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_187_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_187_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][187][]\" value=\"NO\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_187_2\">NO<\/label><\/li><\/ul><div class=\"wpforms-field-description\">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?<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_177-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"177\"><h3 id=\"wpforms-416-field_177\">Employer #3<\/h3><\/div><div id=\"wpforms-416-field_83-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"83\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_84-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"84\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_84\">Employer #3<\/label><input type=\"text\" id=\"wpforms-416-field_84\" class=\"wpforms-field-medium\" name=\"wpforms[fields][84]\" ><div class=\"wpforms-field-description\">Employer #3<\/div><\/div><div id=\"wpforms-416-field_86-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"86\"><label class=\"wpforms-field-label wpforms-label-hide\">Address #3<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-416-field_86\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][86][address1]\" ><label for=\"wpforms-416-field_86\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-416-field_86-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][86][address2]\" ><label for=\"wpforms-416-field_86-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-416-field_86-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][86][city]\" ><label for=\"wpforms-416-field_86-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-416-field_86-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][86][state]\" ><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\"  selected='selected'>Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-416-field_86-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-416-field_86-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][86][postal]\" ><label for=\"wpforms-416-field_86-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-416-field_87-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"87\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_87\">Employer #3<\/label><input type=\"tel\" id=\"wpforms-416-field_87\" class=\"wpforms-field-medium wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][87]\" aria-label=\"Employer #3\" ><div class=\"wpforms-field-description\">Phone<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_85-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"85\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_85\">Position #3<\/label><input type=\"text\" id=\"wpforms-416-field_85\" class=\"wpforms-field-medium\" name=\"wpforms[fields][85]\" ><div class=\"wpforms-field-description\">Position<\/div><\/div><div id=\"wpforms-416-field_92-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"92\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_92\">Job Duties #3<\/label><textarea id=\"wpforms-416-field_92\" class=\"wpforms-field-medium\" name=\"wpforms[fields][92]\" ><\/textarea><div class=\"wpforms-field-description\">Brief Description of Job Duties<\/div><\/div><div id=\"wpforms-416-field_88-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"88\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_88\">Reason for Leaving #3<\/label><input type=\"text\" id=\"wpforms-416-field_88\" class=\"wpforms-field-medium\" name=\"wpforms[fields][88]\" ><div class=\"wpforms-field-description\">Reason for Leaving<\/div><\/div><div id=\"wpforms-416-field_89-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"89\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_89\">Starting Date #3<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_89\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][89][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Starting Date<\/div><\/div><div id=\"wpforms-416-field_90-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"90\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_90\">Ending Date #3<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_90\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][90][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Ending Date<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_94-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"94\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_94\">Employer #3 Contact Name<\/label><input type=\"text\" id=\"wpforms-416-field_94\" class=\"wpforms-field-medium\" name=\"wpforms[fields][94]\" ><div class=\"wpforms-field-description\">Contact Name<\/div><\/div><div id=\"wpforms-416-field_95-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"95\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_95\">Employer #3 Contact Phone<\/label><input type=\"tel\" id=\"wpforms-416-field_95\" class=\"wpforms-field-medium wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][95]\" aria-label=\"Employer #3 Contact Phone\" ><div class=\"wpforms-field-description\">Contact Phone Number<\/div><\/div><div id=\"wpforms-416-field_93-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"93\"><label class=\"wpforms-field-label wpforms-label-hide\">Employer #3 Contact YES\/NO<\/label><ul id=\"wpforms-416-field_93\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_93_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][93][]\" value=\"YES\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_93_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_93_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][93][]\" value=\"NO\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_93_2\">NO<\/label><\/li><\/ul><div class=\"wpforms-field-description\">May we contact your previous Employer?<\/div><\/div><div id=\"wpforms-416-field_190-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"190\"><label class=\"wpforms-field-label wpforms-label-hide\">Employer #3 Federal Motor Carrier Safety<\/label><ul id=\"wpforms-416-field_190\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_190_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][190][]\" value=\"YES\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_190_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_190_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][190][]\" value=\"NO\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_190_2\">NO<\/label><\/li><\/ul><div class=\"wpforms-field-description\">While employed here, were you subject to the Federal Motor Carrier Saftey Regulations?<\/div><\/div><div id=\"wpforms-416-field_189-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"189\"><label class=\"wpforms-field-label wpforms-label-hide\">Employer #3 Alcohol and Controlled Substances Testing<\/label><ul id=\"wpforms-416-field_189\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_189_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][189][]\" value=\"YES\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_189_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_189_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][189][]\" value=\"NO\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_189_2\">NO<\/label><\/li><\/ul><div class=\"wpforms-field-description\">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?<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_109-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"109\"><h3 id=\"wpforms-416-field_109\">Experience and Qualifications<\/h3><\/div><div id=\"wpforms-416-field_110-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"110\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_118-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"118\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_118\">Experience<\/label><textarea id=\"wpforms-416-field_118\" class=\"wpforms-field-medium\" name=\"wpforms[fields][118]\" ><\/textarea><div class=\"wpforms-field-description\">Please show any trucking, transportation or other experience that may help in your work for this company.<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_119-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"119\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_119\">Training<\/label><textarea id=\"wpforms-416-field_119\" class=\"wpforms-field-medium\" name=\"wpforms[fields][119]\" ><\/textarea><div class=\"wpforms-field-description\">Please list courses and training that may help in your work for this company.<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_120-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"120\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_120\">Special Equipment or Technical Materials<\/label><textarea id=\"wpforms-416-field_120\" class=\"wpforms-field-medium\" name=\"wpforms[fields][120]\" ><\/textarea><div class=\"wpforms-field-description\">Please list special equipment and\/or technical materials you can work with.<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_121-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"121\"><h3 id=\"wpforms-416-field_121\">Driving Record and Experience<\/h3><div class=\"wpforms-field-description\">If you will EVER be operating a Company Vehicle here at NWA, please complete the following section. If not, skip to references.<\/div><\/div><div id=\"wpforms-416-field_117-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"117\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_117\">Current Driver&#039;s License Information<\/label><textarea id=\"wpforms-416-field_117\" class=\"wpforms-field-medium\" name=\"wpforms[fields][117]\" ><\/textarea><div class=\"wpforms-field-description\">Please list State Issued Driver's License Type, Licenses Number, Expiration date and which State Issued.<\/div><\/div><div id=\"wpforms-416-field_123-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"123\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-25-25\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-416-field_125-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"125\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_125\">Endorsements<\/label><textarea id=\"wpforms-416-field_125\" class=\"wpforms-field-medium\" name=\"wpforms[fields][125]\" ><\/textarea><div class=\"wpforms-field-description\">Please list any endorsements you have including tanker and Hazmat.<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-416-field_126-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"126\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_126\">States Operated<\/label><textarea id=\"wpforms-416-field_126\" class=\"wpforms-field-medium\" name=\"wpforms[fields][126]\" ><\/textarea><div class=\"wpforms-field-description\">Please list the states in which you have operated for the last five years.<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-416-field_127-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"127\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_127\">Safe Driving Awards<\/label><textarea id=\"wpforms-416-field_127\" class=\"wpforms-field-medium\" name=\"wpforms[fields][127]\" ><\/textarea><div class=\"wpforms-field-description\">Please list which safe driving awards you hold and from whom.<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-416-field_124-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"124\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_124\">Denied, Suspended, Revoked<\/label><textarea id=\"wpforms-416-field_124\" class=\"wpforms-field-medium\" name=\"wpforms[fields][124]\" ><\/textarea><div class=\"wpforms-field-description\">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.<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_158-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"158\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_159-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"159\"><h3 id=\"wpforms-416-field_159\">Equipment<\/h3><div class=\"wpforms-field-description\">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:<\/div><\/div><div id=\"wpforms-416-field_165-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"165\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_165\">Other<\/label><textarea id=\"wpforms-416-field_165\" class=\"wpforms-field-small\" name=\"wpforms[fields][165]\" ><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_160-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"160\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_160\">Straight Truck<\/label><input type=\"text\" id=\"wpforms-416-field_160\" class=\"wpforms-field-medium\" name=\"wpforms[fields][160]\" ><div class=\"wpforms-field-description\">Type, Dates Operated To\/From, and approx. miles.<\/div><\/div><div id=\"wpforms-416-field_162-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"162\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_162\">Motorcoach\/Schoolbus<\/label><input type=\"text\" id=\"wpforms-416-field_162\" class=\"wpforms-field-medium\" name=\"wpforms[fields][162]\" ><div class=\"wpforms-field-description\">Type, Dates Operated To\/From, and approx. miles.<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_161-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"161\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_161\">Tractor and Semi Trailer<\/label><input type=\"text\" id=\"wpforms-416-field_161\" class=\"wpforms-field-medium\" name=\"wpforms[fields][161]\" ><div class=\"wpforms-field-description\">Type, Dates Operated To\/From, and approx. miles.<\/div><\/div><div id=\"wpforms-416-field_163-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"163\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_163\">Tractor &amp; Two Trailers<\/label><input type=\"text\" id=\"wpforms-416-field_163\" class=\"wpforms-field-medium\" name=\"wpforms[fields][163]\" ><div class=\"wpforms-field-description\">Type, Dates Operated To\/From, and approx. miles.<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_139-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"139\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-416-field_128-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"128\"><h3 id=\"wpforms-416-field_128\">Accident Record<\/h3><div class=\"wpforms-field-description\">Please list any accidents for the past 3 years.  Please attach .pdf for more history if necessary.<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-416-field_140-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"140\"><label class=\"wpforms-field-label\">Accident in the past 3 years. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-416-field_140\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_140_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][140][]\" value=\"YES\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_140_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_140_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][140][]\" value=\"NO\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_140_2\">NO<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_140_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][140][]\" value=\"YES, MORE THAN 3\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_140_4\">YES, MORE THAN 3<\/label><\/li><\/ul><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_132-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"132\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_129-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"129\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_129\">Date of Accident #1<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_129\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][129][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Date<\/div><\/div><div id=\"wpforms-416-field_133-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"133\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_133\">Date of Accident #2<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_133\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][133][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Date<\/div><\/div><div id=\"wpforms-416-field_136-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"136\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_136\">Date of Accident #3<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_136\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][136][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Date<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_130-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"130\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_130\">Nature of Accident #1<\/label><input type=\"text\" id=\"wpforms-416-field_130\" class=\"wpforms-field-medium\" name=\"wpforms[fields][130]\" ><div class=\"wpforms-field-description\">Nature of Accident (Head-On, Rear-End, Upset, etc)<\/div><\/div><div id=\"wpforms-416-field_134-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"134\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_134\">Nature of Accident #2<\/label><input type=\"text\" id=\"wpforms-416-field_134\" class=\"wpforms-field-medium\" name=\"wpforms[fields][134]\" ><div class=\"wpforms-field-description\">Nature of Accident (Head-On, Rear-End, Upset, etc)<\/div><\/div><div id=\"wpforms-416-field_137-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"137\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_137\">Nature of Accident #3<\/label><input type=\"text\" id=\"wpforms-416-field_137\" class=\"wpforms-field-medium\" name=\"wpforms[fields][137]\" ><div class=\"wpforms-field-description\">Nature of Accident (Head-On, Rear-End, Upset, etc)<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_131-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"131\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_131\">Fatalties\/Injuries of Accident #1<\/label><input type=\"text\" id=\"wpforms-416-field_131\" class=\"wpforms-field-medium\" name=\"wpforms[fields][131]\" ><div class=\"wpforms-field-description\">Please list any injuries or fatalities.<\/div><\/div><div id=\"wpforms-416-field_135-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"135\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_135\">Fatalties\/Injuries of Accident #2<\/label><input type=\"text\" id=\"wpforms-416-field_135\" class=\"wpforms-field-medium\" name=\"wpforms[fields][135]\" ><div class=\"wpforms-field-description\">Please list any injuries or fatalities.<\/div><\/div><div id=\"wpforms-416-field_138-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"138\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_138\">Fatalties\/Injuries of Accident #3<\/label><input type=\"text\" id=\"wpforms-416-field_138\" class=\"wpforms-field-medium\" name=\"wpforms[fields][138]\" ><div class=\"wpforms-field-description\">Please list any injuries or fatalities.<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_143-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"143\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-416-field_142-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"142\"><h3 id=\"wpforms-416-field_142\">Traffic Convictions and Forfeitures<\/h3><div class=\"wpforms-field-description\">Please list any traffic convictions and forfeitures (other than parking violations) for the past 3 years.  Please attach .pdf for more history if necessary.<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-416-field_144-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"144\"><label class=\"wpforms-field-label\">Traffic Conviction\/Forfeiture in the past 3 years. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-416-field_144\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_144_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][144][]\" value=\"YES\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_144_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_144_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][144][]\" value=\"NO\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_144_2\">NO<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_144_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][144][]\" value=\"YES, MORE THAN 3\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_144_4\">YES, MORE THAN 3<\/label><\/li><\/ul><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_145-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"145\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-25-25\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-416-field_146-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"146\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_146\">Date of Traffic #1<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_146\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][146][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Date<\/div><\/div><div id=\"wpforms-416-field_147-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"147\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_147\">Date of Traffic #2<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_147\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][147][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Date<\/div><\/div><div id=\"wpforms-416-field_148-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"148\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_148\">Date of Traffic #3<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_148\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][148][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Date<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-416-field_149-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"149\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_149\">Location of Traffic #1<\/label><input type=\"text\" id=\"wpforms-416-field_149\" class=\"wpforms-field-medium\" name=\"wpforms[fields][149]\" ><div class=\"wpforms-field-description\">Location<\/div><\/div><div id=\"wpforms-416-field_150-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"150\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_150\">Location of Traffic #2<\/label><input type=\"text\" id=\"wpforms-416-field_150\" class=\"wpforms-field-medium\" name=\"wpforms[fields][150]\" ><div class=\"wpforms-field-description\">Location<\/div><\/div><div id=\"wpforms-416-field_151-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"151\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_151\">Location of Traffic #2<\/label><input type=\"text\" id=\"wpforms-416-field_151\" class=\"wpforms-field-medium\" name=\"wpforms[fields][151]\" ><div class=\"wpforms-field-description\">Location<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-416-field_152-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"152\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_152\">Traffic Charge #1<\/label><input type=\"text\" id=\"wpforms-416-field_152\" class=\"wpforms-field-medium\" name=\"wpforms[fields][152]\" ><div class=\"wpforms-field-description\">Charge<\/div><\/div><div id=\"wpforms-416-field_153-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"153\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_153\">Traffic Charge #2<\/label><input type=\"text\" id=\"wpforms-416-field_153\" class=\"wpforms-field-medium\" name=\"wpforms[fields][153]\" ><div class=\"wpforms-field-description\">Charge<\/div><\/div><div id=\"wpforms-416-field_154-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"154\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_154\">Traffic Charge #3<\/label><input type=\"text\" id=\"wpforms-416-field_154\" class=\"wpforms-field-medium\" name=\"wpforms[fields][154]\" ><div class=\"wpforms-field-description\">Charge<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-416-field_155-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"155\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_155\">Traffic Penalty #1<\/label><input type=\"text\" id=\"wpforms-416-field_155\" class=\"wpforms-field-medium\" name=\"wpforms[fields][155]\" ><div class=\"wpforms-field-description\">Please list any penalties associated.<\/div><\/div><div id=\"wpforms-416-field_156-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"156\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_156\">Traffic Penalty #2<\/label><input type=\"text\" id=\"wpforms-416-field_156\" class=\"wpforms-field-medium\" name=\"wpforms[fields][156]\" ><div class=\"wpforms-field-description\">Please list any penalties associated.<\/div><\/div><div id=\"wpforms-416-field_157-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"157\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_157\">Traffic Penalty #3<\/label><input type=\"text\" id=\"wpforms-416-field_157\" class=\"wpforms-field-medium\" name=\"wpforms[fields][157]\" ><div class=\"wpforms-field-description\">Please list any penalties associated.<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_179-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"179\"><h3 id=\"wpforms-416-field_179\">References<\/h3><div class=\"wpforms-field-description\">Please list the name, address and phone number and years you have known your reference.<\/div><\/div><div id=\"wpforms-416-field_178-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"178\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_180-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"180\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_180\">Reference #1<\/label><textarea id=\"wpforms-416-field_180\" class=\"wpforms-field-medium\" name=\"wpforms[fields][180]\" ><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_181-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"181\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_181\">Reference #2<\/label><textarea id=\"wpforms-416-field_181\" class=\"wpforms-field-medium\" name=\"wpforms[fields][181]\" ><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_182-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"182\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_182\">Reference #3<\/label><textarea id=\"wpforms-416-field_182\" class=\"wpforms-field-medium\" name=\"wpforms[fields][182]\" ><\/textarea><\/div><\/div><\/div><\/div><div id=\"wpforms-416-field_34-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_34\">Please attach your Resume or CV and additional history if neccesary.<\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"34\"\n\t\tdata-form-id=\"416\"\n\t\tdata-input-name=\"wpforms_416_34\"\n\t\tdata-extensions=\"pdf\"\n\t\tdata-max-size=\"67108864\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"67108864\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag a file to this area to upload.<\/span>\n\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-416-field_34\"\n\t\tname=\"wpforms_416_34\" \t\tvalue=\"\">\n<div class=\"wpforms-field-description\">Please upload in .pdf format only.<\/div><\/div><div id=\"wpforms-416-field_167-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"167\"><h3 id=\"wpforms-416-field_167\">TO BE READ AND SIGNED BY APPLICANT *<\/h3><div class=\"wpforms-field-description\">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.<\/div><\/div><div id=\"wpforms-416-field_191-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"191\"><label class=\"wpforms-field-label\" for=\"wpforms-416-field_191\">Signature <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-416-field_191\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][191]\" autocomplete=\"off\" inputmode=\"none\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-416-field_191-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-416-field_4-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"4\"><label class=\"wpforms-field-label wpforms-label-hide\">Drug Test <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-416-field_4\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-416-field_4_1\" name=\"wpforms[fields][4][]\" value=\"This employer requires a pre-employment drug test.  Please check this box to confirm you have read this section. *\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-416-field_4_1\">This employer requires a pre-employment drug test.  Please check this box to confirm you have read this section. *<\/label><\/li><\/ul><div class=\"wpforms-field-description\">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.<\/div><\/div><div id=\"wpforms-416-field_192-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"192\"><h3 id=\"wpforms-416-field_192\">MVR Release Consent Form<\/h3><div class=\"wpforms-field-description\">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.<\/div><\/div><div id=\"wpforms-416-field_210-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"210\"><h3 id=\"wpforms-416-field_210\">In conjunction with my employment, at Northwest Asphalt Inc. (&quot;the company&quot;), I\u00a0 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.<\/h3><\/div><div id=\"wpforms-416-field_199-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"199\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_200-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"200\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_200\">MVR - Name<\/label><input type=\"text\" id=\"wpforms-416-field_200\" class=\"wpforms-field-medium\" name=\"wpforms[fields][200]\" ><div class=\"wpforms-field-description\">Applicant Name<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_201-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"201\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_201\">MVR - Date of Birth<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-416-field_201\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][201][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Date of Birth<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><\/div><\/div><\/div><div id=\"wpforms-416-field_206-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"206\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_202-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"202\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_202\">MVR - Driver&#039;s License Number<\/label><input type=\"text\" id=\"wpforms-416-field_202\" class=\"wpforms-field-medium\" name=\"wpforms[fields][202]\" ><div class=\"wpforms-field-description\">Driver's License Number<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_203-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"203\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_203\">MVR - Driver&#039;s License State<\/label><input type=\"text\" id=\"wpforms-416-field_203\" class=\"wpforms-field-medium\" name=\"wpforms[fields][203]\" ><div class=\"wpforms-field-description\">Driver's License Issuing State<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-416-field_208-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"208\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-416-field_208\">MVR - 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