K&B Transportation, Inc. - Safety & Compliance Management Position

We consider applications for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

Position Applied For:		Date of Application:

How Did You Learn About Us?
Advertisement	Friend	Walk-In
Employment Agency	Relative	Other

Personal Information
Last Name	First Name			Middle
Address	City		State		Zip
Telephone	SSN

Previous Addresses
Address 1		From To
Address 1		From To
Address 1		From To

If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No
Have you ever filed an application with us before? Yes No If yes, give date
Have you ever been employed with us before? Yes No If yes, give date
May we contact your present employer? Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status Yes No Proof of citizenship or immigration status will be required upon employment
On what date would you be available for work?
Are you available to work: Full Time Part Time Shift Work Temporary
Are you currently on "lay-off" status and subject to recall? Yes No
Can you travel if a job requires it? Yes No
Have you been convicted of a felony within the last 7 years? Yes No
Conviction will not necessarily disqualify an applicant from employment.
if yes, please explain:
Have you ever tested positive for drugs or alcohol? Yes No
if yes, please explain:

Education
	Elementary	High School	Undergraduate	Graduate/Professional
School Name
School Location
Years Completed
Date Graduate
Course of Study
State any additional information you feel may be helpful to us in considering your application

Indicate any foreign languages you can speak, read and/or write
	Fluent	Good	Fair
Speak
Read
Write

List professional, trade, business or civic activities and offices held You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or handicap or other protected status:


References
Give name, address, and telephone number of three references who are not related to you and are not previous employers.
1)
2)
3)

Have you ever had any job-related training in the United States military? Yes No
If yes, please describe:
Are you physically or otherwise unable to perform the duties of the job for which you are applying? Yes No

Employment Experience - Past Ten Years

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status. List any period of unemployment and reason for such.

Previous Employer 1
Employer	Start Date	End Date
Address	Starting Salary	End Salary
Telephone
Job Title	Supervisor
Reason For Leaving

Description of work

Previous Employer 2
Employer	Start Date	End Date
Address	Starting Salary	End Salary
Telephone
Job Title	Supervisor
Reason For Leaving

Description of work

Previous Employer 3
Employer	Start Date	End Date
Address	Starting Salary	End Salary
Telephone
Job Title	Supervisor
Reason For Leaving

Description of work

Previous Employer 4
Employer	Start Date	End Date
Address	Starting Salary	End Salary
Telephone
Job Title	Supervisor
Reason For Leaving

Description of work

Special Skills and Qualifications

Applicants Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time no to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

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

If requested to do so, I agree to submit to a physical and psychological testing, including, but not limited to, a polygraph and/or urine analysis to test for drugs.

"I certify that I personally completed this application and that all of the information is true and correct. Per section 391.23 I understand that I have the following rights: (1) to review information provided by the previous employers (DOT regulated history in the preceding 3 years). (2) to have errors in the information corrected by previous employers and for that previous employer to resend the corrected information to us, (3) to have a rebuttal statement attached to any alleged erroneous information, if you and a previous employer cannot agree on the accuracy of the information. Requests must be submitted in writing at any time including when applying or up to 30 days after being employed. (no fax or verbal requests). Further, you are hereby authorized to give to K&B Transportation/Artex, Inc. all information regarding my character, work habits, dates of employment, traffic offenses, credit, experience, & safety record. You are also authorized to release the results of all drug & alcohol tests in accordance with sections 382.413, 382.405, 391.89 & 391.23 of the Federal Motor Carrier Safety Regulations. You and K&B Transportation/Artex, Inc. are hereby released from any liability, which may result from giving such information, in order to enable K&B Transportation, Inc. to comply with the requirements of 382.413 & 391.23 of the FMCSR. I specifically authorize you to release information on any/all alcohol tests with a concentration of 0.04 or greater, positive controlled substance tests, and/or refusals to be tested within the three (3) years preceding the date of this request. I authorize you to release any and all information pertaining to my evaluation by a substance abuse professional (SAP), the identity of that SAP, and my participation in any/all treatment or rehabilitation recommended by the SAP, I hereby authorize and direct my current and/or prior employers/lessors to release such information to K&B Transportation/Artex, in personal interviews, telephone interviews, letters, or any other method that ensures confidentiality. Furthermore, I authorize K&B Transportation to request criminal records, motor vehicle records, and transportation history from third party sources including, but not limited to ordering information from USIS. I also authorize K&B Transportation to obtain my safety performance history through FMCSA's Commercial Driver Pre-Employment Screening Program through either FMCSA or their third party provider. I hereby authorize K&B Transportation/Artex to release such information to any of its personnel whose duties require them to assess this application and/or to make recommendations or decisions with respect to it. Under section 391.23(g)(1) you must reply with such information as soon as possible or NLT 30 days from the date of this request. Fax replies to: 402-494-1760. I have completed the application of my own free will and hold all clients of You and K&B transportation/Artex Inc., harmless of all liability for providing this application for my use.

Signature

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Date