First Name*
Last Name*
Email Address*
Phone*
TO BE READ AND SIGNED BY APPLICANT
I authorize Select Genetics, LLC and its representatives on their behalf, to make such investigations and inquiries 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 inquiries and releasing information in connection with my application.
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 abide by all rules and regulations of the 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), as well as for employment verification and validation of information on my application. 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.*
Yes No
I have been informed that my previous DOT Regulated employment history in the previous 3 years can be reviewed by my submitting a written request to the prospective employer, which may be done at any time, including when applying or as late as 30 days after being employed or being notified of denial of employment. Select Genetics, LLC has advised me that within 5 business days after receiving my request or within 5 business days of receiving the information, they will supply the information to me. Select Genetics, LLC has advised me that if I have not arranged to pick up or receive the requested records from previous employers within thirty (30) days of making them available, this company may consider I have waived the request to review the records.
All information is to be used in the decision making for employment with Select Genetics, LLC.
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.*
Yes
PREVIOUS THREE YEARS RESIDENCY
Address (Street, City, State and Zip code) - 1
# Years at this address - 1
Address (Street, City, State and Zip code) - 2
# Years at this address - 2
Address (Street, City, State and Zip code) - 3
# Years at this address - 3
Date of Birth*
Social Security Number
EMERGENCY CONTACT
Name
Address
Phone Number
Do you have the legal right to work in the United States?*
Yes No
Can you provide proof of age?*
Yes No
Have you worked for this company before?*
Yes No
If yes, where?
Dates previously worked here: (From____ To ______)
Previous Rate of Pay
Previous Position
Reason for Leaving
Are you now employed?
Yes No
If not, how long since leaving last employment?
Who referred you?
Rate of pay expected?
Have you ever been bonded?
Yes No
If yes, name of bonding company:
Is there any reason you might be unable to perform the function of the job for which you have applied [as described in the job description]?
Yes No
If yes, explain if you wish.
EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle (total of ten (10) years employment record).
*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
Must list the complete mailing address: street number and name, city, state and zip code.
LAST EMPLOYER NAME - 1
LAST EMPLOYER ADDRESS - 1
(Street number, city, state and zip code)
LAST EMPLOYER CONTACT PERSON - 1
PHONE NUMBER - 1
DATES EMPLOYED - 1
POSITION HELD - 1
SALARY/WAGE - 1
REASON FOR LEAVING? - 1
Were you subject to the FMCSRs* while employed? - 1
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weights or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? - 1
Yes No
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON.
SECOND LAST EMPLOYER NAME - 2
SECOND LAST EMPLOYER ADDRESS - 2
(Street number, city, state and zip code)
SECOND LAST EMPLOYER CONTACT PERSON - 2
PHONE NUMBER - 2
DATES EMPLOYED - 2
POSITION HELD - 2
SALARY/WAGE - 2
REASON FOR LEAVING - 2
Were you subject to the FMCSRs* while employed? - 2
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weights or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? - 2
Yes No
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON.
I consent to be contacted over SMS/Text for this job.