Blackjack Pizza Application Form – Fill Out and Use This PDF

GENERAL

SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK:

U.S. MILITARY OR		PRESENT MEMBERSHIP IN
NAVAL SERVICE	RANK	NATIONAL GUARD OR RESERVES

WORK EXPERIENCE

Note: Start with most recent position, furnish dates and explanations for each period of unemployment of one month or more. A résumé providing this information may be attached as a supplement.

DATE			NAME AND ADDRESS OF EMPLOYER			POSITION
MONTH AND YEAR			(PLEASE INCLUDE PHONE NUMBER)
Start Date	Leave Date
Salary		Reason for leaving
Start Date	Leave Date
Salary		Reason for leaving
Start Date	Leave Date
Salary		Reason for leaving
Start Date	Leave Date
Salary		Reason for leaving
REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE
YEAR.
NAME			ADDRESS	TELEPHONE NUMBER		YEARS ACQUAINTED
1.
2.
3.

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PLEASE REVIEW THE DUTIES OF THIS POSITION AS OUTLINED IN THE JOB POSTING/DESCRIPTION. CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THIS JOB? o Yes o No

IF NOT, WHAT CAN BE DONE TO ACCOMMODATE YOUR LIMITATION?

DESCRIBE:

IN CASE OF EMERGENCY NOTIFY:

NAME

ADDRESS

PHONE NO.

DELIVERYDRIVERSONLY:

A copy of the following is required from each applicant: a) Driver’s License; b) Vehicle Registration; and c) Auto Liability Insurance Policy (Vehicle only)

Name of company insured with:					Policy Number:
Name of Insured (or Policyholder):
Policy Effective Date:					Policy Expiration Date:

Have you ever been convicted of a crime involving a motor vehicle, including vehicular homicide or assault? o Yes o No

In the last 5 years, have you ever received a violation for DUI or open container/chemical test failure/possession of a controlled substance? o Yes o No

Has your driver’s license ever been suspended or revoked o Yes o No If yes, please explain:

The information I have supplied is complete and accurate. I authorize the Company to verify this information now and in the future, and understand that I may be terminated at any time if my driving record does not meet Company requirements.

If I am employed as a delivery driver by the Company, I also agree to maintain, at my cost, personal auto liability insurance at the mandatory state liability limits for the state(s) in which I will be driving. I agree to renew my driver’s license before expiration. I understand that Blackjack Pizza and the Company are not responsible for damage to my vehicle, and I agree to have continuously in force auto liability insurance that will cover my vehicle while working here. I agree that it is my responsibility to consult with my insurance agent to maintain adequate insurance.

I UNDERSTAND THAT BLACKJACK PIZZA AND THE COMPANY DO NOT WANT ME TO EVER SPEED OR DRIVE RECKLESSLY IN ANY WAY. I WILL REPORT ANY INSTRUCTIONS TO DO OTHERWISE TO THE BLACKJACK PIZZA CORPORATE OFFICE.

I AGREE TO OBEY THE FOLLOWING POLICIES WHILE WORKING:

1.To always drive courteously, safely, and follow defensive driving techniques while obeying all laws.

2.To notify the Company if there is any change in my car insurance.

3.To notify the Company if my driving privileges are restricted, suspended, or revoked, and in the event I receive a ticket, on or off the job.

4.To always use my seat belt while working here and keep my radio/music system to a volume level my supervisor finds acceptable at all times.

5.To be employed here as a driver it is up to me to supply a clean, safe, dependable vehicle with proper insurance. I realize that if I am employed as a driver, my employment can be terminated if my car is not in proper working order.

6.To never allow anyone else to ride with me while working, unless instructed by my supervisor.

7.To never eat or drink while driving.

8.To discuss with my supervisor any incident involving a vehicle that happens while working, no matter whose fault, and whether or not there were any injuries.

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