Elite Blasting Services LLC

Stony Point, NC | Jefferson, Georgia | Jacksboro, Tenn

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Employee Application Form

Date *

Name *

Address *

City , State, Zip *

Phone *

Date Of Birth *

List your residency for the past 3 years *

Previous Address How Long

Driver License # *

Type of License *

State *

Accident Record For Past 3 Years: If None, Write None or NA

Date

Nature Of Accident

Fatalities

Injuries

Date

Nature Of Accident

Fatalities

Injuries

Driving Experience and Class Of Equipment

Straight Truck Type Of Equipment

Date From

Date To

Approximate Number Of Miles

Tractor and Semi-Trailer

Type Of Equipment

Date From

Date To

Approximate Number Of Miles

Type Of Equipment

Date From

Date To

Approximate Number Of Miles

Other

Type Of Equipment

Date From

Date To

Approximate Number Of Miles

List Employment History

Last Employer: Name *

Address *

Phone

Was The Position Under FMCSA Regulations?

Were You In An ACTIVE Drug And Alcohol Testing Program?

Position Held *

From *

To *

Salary *

Reason For Leaving *

Second Employer: Name

Address

Phone

Was The Position Under FMCSA Regulations?

Were You In An ACTIVE Drug And Alcohol Testing Program?

Position Held

From

Salary

Reason For Leaving

Third Employer: Name

Address

Phone

Was The Position Under FMCSA Regulations?

Were You In An ACTIVE Drug And Alcohol Testing Program?

Position Held

From

Salary

Reason For Leaving

Forth Employer: Name

Address

Phone

Was The Position Under FMCSA Regulations?

Were You In An ACTIVE Drug And Alcohol Testing Program?

Position Held

From

Salary

Reason For Leaving

A. Have you ever had any type of motor vehicle license suspended or revoked, or ever been denied a license, Permit or privilege to operate a motor vehicle ? *

YesNo

B. Do you have a pending charge or past conviction for driving while intoxicated ?*

YesNo

C. Do you have pending charge or past conviction or possession of controlled substance ?*

YesNo

D. Have you ever been denied auto liability insurance ?*

YesNo

E. Do you have a pending charge or conviction for any misdemeanor or felony offense ? *

YesNo

F. Have you tested positive, or refused to test, on any pre-employment drug test or have you tested .02 or greater, or refused to test, on any pre-employment alcohol test during the past two years*

YesNo

Application Addendum

Federal Motor Carrier Safety Regulations §40.25 (j) The Employer must ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for

Rights

Pursuant to 49CFR, part 391.23 (j), you have the following rights regarding investigative information 1. The right to review information provided by previous employers. 2. The right to have errors in the information corrected by the previous and for that

To Be Read And Signed By Applicant

This certifies that I completed this application, 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 inquire of my personal, employment, financial or medical

Applicants Signature *

Date *