Syfan Dedicated Employment Application Form – Fill Out and Use This PDF

Application for Employment

Company Name: SYFAN DEDICATED INC.		Phone Number: 770-287-8485
Street Address: PO BOX 1294	2037 OLD CANDLER ROAD	Fax Number: 770-531-7878
City, State, Zip: GAINESVILLE GA 30503

This company operates in compliance with Federal and State equal opportunity laws. Qualified applicants are considered for all positions without regard to race, color, religion, national origin, age, marital status, veteran status, non-job related disability or any other protected group status.

_______________________________________________________________			_________________________
Signature of Applicant			Date
Name ______________________________________________________________			_________________________
First	Middle	Last	Phone

*Current Address __________________________________________________________________________________

StreetCity State Zip Code

*If at the above resident less than three years, list below all residences for the past three years. Attach a separate sheet if necessary.

_________________________________________________________________________________________________

StreetCity State Zip Code

_________________________________________________________________________________________________

Street	City	State	Zip Code
Position Applying for _____________________________	Temporary_______ Part Time _______ Full Time _______

Is there any reason you might not be able to perform the function of the job for which you have applied? ____________

If yes, explain _____________________________________________________________________________________

Who Referred You?______________________________	Rate of Pay Expected? ____________________________
Have you ever worked for this company before? _________	Dates: From _________________ to ________________
	month/year	month/year

Have you ever worked for this company under another name? ______ If so, under what name? ____________________

Where? _______________________ Rate of Pay ____________________ Position _________________________

Reason for Leaving ________________________________________________________________________________

Names of any relatives employed by this company _______________________________________________________

Are you currently employed? ________________ If not, how long since leaving last employment?_________________

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

	EDUCATION
Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12	College: 1 2 3 4

Last school attended ________________________________________________________________________________

Name	City/State

GENERAL

Have you ever been bonded? _________ Name of Bonding Company ______________________________________

Have you ever tested positive on a drug test? ________ Have you ever tested 0.04 or higher on an alcohol test? ________

Have you ever been convicted of a felony and/or misdemeanor? _________ If yes, please explain fully on a separate sheet of paper. Conviction

of a crime is not an automatic bar to employment - all circumstances will be considered.

DRIVER EXPERIENCE AND QUALIFICATION

Date of Birth _________________ The U.S. Department of Transportation requires that driver applicants state their date

Month/day/year of birth 391.2(b)(1)

Social Security Number ________ - ______ - ______

PHYSICAL HISTORY

The U.S. Department of Transportation requires that all driver applicants pass certain physical tests before they are hired to

drive a motor carrier. FMCSR 391 Subpart E.

Date of last Department of Transportation prescribed examination ________________

Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, leg, hand or arm? Yes ______ No ______

		DRIVER EXPERIENCE AND QUALIFICATION (cont’d)
Licenses
Driver	State	License Number	Type	Expiration Date
Licenses held	_____	________________	_____	_____________
in past 3 years	_____	________________	_____	_____________
must be shown	_____	________________	_____	_____________

A.Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes _____ No _____

B.Has any license, permit or privilege ever been suspended or revoked? Yes _____ No _____

C.Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations: Yes _____ No _____

D.Do you have more than one valid driver’s license? Yes _____ No _____

E.Is the issuing state of your current driver’s license the same as your state of residence? Yes _____ No _____

If you answered “No”, attach a statement giving details.

Driving Experience
Class of Equipment	Type of Equipment		Dates	Approximate
	(Van, Reefer, Tank, Flat, Etc)	From	To	Total Miles
Tractor and Semi-Trailer	________________________	______________		__________
Straight Truck	________________________	______________		__________
Twin	________________________	______________		__________
Other	________________________	______________		__________

List states operated in during the last five years ____________________________________________________________

__________________________________________________________________________________________________

List special courses or training that will help you as a driver __________________________________________________

List safe driving awards held and who awards were presented by ______________________________________________

Accident Review for the past 3 years (attach a separate sheet of paper if more space is needed). If none, write NONE.

Dates	Nature of Accident (Head-On, Rear-End, Upset)	Fatalities	Injuries
_________	_______________________________________	_______	______
_________	_______________________________________	_______	______
_________	_______________________________________	_______	______

Traffic Convictions and Forfeitures for the past 3 years other than parking violations. If none, write NONE.

Location	Date	Charge	Penalty
____________________	________	____________	_______________
____________________	________	____________	_______________
____________________	________	____________	_______________

EMPLOYMENT RECORD

The U.S. Department of Transportation requires that driver applicants show all employment for the past three years. In accordance with CFR391.21 (b)(10), (11), they must also show commercial driving employment for the seven years preceding this three year period.

Start with the last or current position, including any military experience, and work back.

Current Employer: __________________________________ Supervisor’s Name: ______________________________

Address: ___________________________________________________________ Phone: ( ) ___________________

Position Held: _____________________________________ From ___________ To ___________ Salary ____________

Mo./Yr. Mo./Yr.

Reason for Leaving: _________________________________________________________________________________

Were you subject to the FMCSR’s while employed? Yes ____ No _____

Was your job designated as a safety-sensitive function to be subject to DOT Drug and Alcohol testing? Yes _____No _____

Previous Employer: __________________________________ Supervisor’s Name: ______________________________

Address: ___________________________________________________________ Phone: ( ) ___________________

Position Held: _____________________________________ From ___________ To ___________ Salary ____________

Mo./Yr. Mo./Yr.

Reason for Leaving: _________________________________________________________________________________

Were you subject to the FMCSR’s while employed? Yes ____ No _____

Was your job designated as a safety-sensitive function to be subject to DOT Drug and Alcohol testing? Yes _____No _____

Previous Employer: __________________________________ Supervisor’s Name: ______________________________

Address: ___________________________________________________________ Phone: ( ) ___________________

Position Held: _____________________________________ From ___________ To ___________ Salary ____________

Mo./Yr. Mo./Yr.

Reason for Leaving: _________________________________________________________________________________

Were you subject to the FMCSR’s while employed? Yes ____ No _____

Was your job designated as a safety-sensitive function to be subject to DOT Drug and Alcohol testing? Yes _____No _____

Previous Employer: __________________________________ Supervisor’s Name: ______________________________

Address: ___________________________________________________________ Phone: ( ) ___________________

Position Held: _____________________________________ From ___________ To ___________ Salary ____________

Mo./Yr. Mo./Yr.

Reason for Leaving: _________________________________________________________________________________

Were you subject to the FMCSR’s while employed? Yes ____ No _____

Was your job designated as a safety-sensitive function to be subject to DOT Drug and Alcohol testing? Yes _____No _____

Previous Employer: __________________________________ Supervisor’s Name: ______________________________

Address: ___________________________________________________________ Phone: ( ) ___________________

Position Held: _____________________________________ From ___________ To ___________ Salary ____________

Mo./Yr. Mo./Yr.

Reason for Leaving: _________________________________________________________________________________

Were you subject to the FMCSR’s while employed? Yes ____ No _____

Was your job designated as a safety-sensitive function to be subject to DOT Drug and Alcohol testing? Yes _____No _____

Previous Employer: __________________________________ Supervisor’s Name: ______________________________

Address: ___________________________________________________________ Phone: ( ) ___________________

Position Held: _____________________________________ From ___________ To ___________ Salary ____________

Mo./Yr. Mo./Yr.

Reason for Leaving: _________________________________________________________________________________

Were you subject to the FMCSR’s while employed? Yes ____ No _____

Was your job designated as a safety-sensitive function to be subject to DOT Drug and Alcohol testing? Yes _____No _____

Previous Employer: __________________________________ Supervisor’s Name: ______________________________

Address: ___________________________________________________________ Phone: ( ) ___________________

Position Held: _____________________________________ From ___________ To ___________ Salary ____________

Mo./Yr. Mo./Yr.

Reason for Leaving: _________________________________________________________________________________

Were you subject to the FMCSR’s while employed? Yes ____ No _____

Was your job designated as a safety-sensitive function to be subject to DOT Drug and Alcohol testing? Yes _____No _____

Previous Employer: __________________________________ Supervisor’s Name: ______________________________

Address: ___________________________________________________________ Phone: ( ) ___________________

Position Held: _____________________________________ From ___________ To ___________ Salary ____________

Mo./Yr. Mo./Yr.

Reason for Leaving: _________________________________________________________________________________

Were you subject to the FMCSR’s while employed? Yes ____ No _____

Was your job designated as a safety-sensitive function to be subject to DOT Drug and Alcohol testing? Yes _____No _____

Previous Employer: __________________________________ Supervisor’s Name: ______________________________

Address: ___________________________________________________________ Phone: ( ) ___________________

Position Held: _____________________________________ From ___________ To ___________ Salary ____________

Mo./Yr. Mo./Yr.

Reason for Leaving: _________________________________________________________________________________

Were you subject to the FMCSR’s while employed? Yes ____ No _____

Was your job designated as a safety-sensitive function to be subject to DOT Drug and Alcohol testing? Yes _____No _____

Previous Employer: __________________________________ Supervisor’s Name: ______________________________

Address: ___________________________________________________________ Phone: ( ) ___________________

Position Held: _____________________________________ From ___________ To ___________ Salary ____________

Mo./Yr. Mo./Yr.

Reason for Leaving: _________________________________________________________________________________

Were you subject to the FMCSR’s while employed? Yes ____ No _____

Was your job designated as a safety-sensitive function to be subject to DOT Drug and Alcohol testing? Yes _____No _____

APPLICANT MUST READ AND SIGN

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

INVESTIGATION

I authorize you or your agents to make sure investigations and inquiries of my personal, employment, financial or medical and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

If the event of employment, I understand that false or misleading information given in my application and/or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of this Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

*Review information provided by previous employers;

*Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and

*Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

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.

_________________________________________________________________________________________________

Date	Applicant’s Signature

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