Employment Application Personal InformationFirst Name*Last Name*Date* Social Security Number*Date of Birth* Current AddressStreet*City*StateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipcode*How Long?*If at above address for less than three years, list below all residences for the past three years.StreetCityStateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipcodeHow Long?StreetCityStateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipcodeHow Long?Phone NumberHome Phone*Cell Phone*Emergency ContactName*Emergency Phone*EXPERIENCE & QUALIFICATIONSType of LicenseStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense NumberDate DRIVING EXPERIENCEClass of EquipmentType of EquipmentDate From Date To Miles DrivenClass of EquipmentType of EquipmentDate From Date To Miles DrivenClass of EquipmentType of EquipmentDate From Date To Miles DrivenACCIDENT RECORD FOR PAST 3 YEARSDate Nature of AccidentInjuriesFatalitiesDate Nature of AccidentInjuriesFatalitiesDate Nature of AccidentInjuriesFatalitiesTRAFFIC CONVICTIONS & FORFEITURES FOR PAST 3 YEARSLocationDate ChargePenaltyLocationDate ChargePenaltyLocationDate ChargePenaltyA. Have you ever been denied a license, permit or privilege to operate a motor vehicle?*YesNoB. Has any license, permit or privilege ever been suspended or revoked?*YesNoC. Have you ever been convicted of a felony?*YesNoIF THE ASNWER TO EITHER A, B OR C IS YES, PLEASE INCLUDE DETAILS.* *Note you are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to Connecticut General Statutes 46b-146, 54-76o or 54-142a. Criminal records subject to erasure pursuant to 46b-146, 54-76o or 54-142a are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon. Any person whose criminal records have been erased pursuant to ยงยง46b-146, 54-76o or 54-142a shall be deemed to have never been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear under oath.APPLICANT: AS REQUIRED BY THE US DOT, THE INFORMATION PROVIDED ON THIS PAGE PERTAINING TO PREVIOUS EMPLOYMENT HISTORY MAY BE USED AND YOUR PREVIOUS EMPLOYERS WILL BE CONTACTED FOR THE PURPOSE OF INVESTIGATING YOUR SAFETY PERFORMANCE HISTORY. UNDER DOT REGULATIONS, YOU HAVE THE RIGHT TO REVIEW AND REBUT INFORMATION PROVIDED BY A PREVIOUS EMPLOYER. APPLICANTS WISHING TO REVIEW PREVIOUS EMPLOYER-PROVIDED INVESTIGATIVE INFORMATION MUST SUBMIT A WRITTEN REQUEST TO THE PROSPECTIVE EMPLOYER. PLEASE SEE THE PROSPECTIVE EMPLOYER AND THE FEDERAL MOTOR CARRIER SAFETY REGULATIONSFOR YOUR SPECIFIC RIGHTS UNDER THIS US DOT REGULATION 391.23.Employment RecordCurrent EmployerSupervisor NameAddressPhone #Position HeldDate From Date To Reason for LeavingPrevious EmployerSupervisor NameAddressPhone #Position HeldDate From Date To Reason for LeavingPrevious EmployerSupervisor NameAddressPhone #Position HeldDate From Date To Reason for LeavingSignature*