DOT Application Form

To be read and accepted by the applicant

I authorize you 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). 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.

Please note, you must check the box below in order to be able to submit your application:

I accept terms

First Name*

Middle Initial*

Last Name*

Applicant to Complete

Position Applied For*

Today's Date*

Phone

First Name*

Middle Initial*

Last Name*

Email Address*

Social Security Number

List your addresses for the past 3 years

Current Address:

Street Address*

Address Line 2

City*

State*

Zip Code*

How long have you been at this address?*

Previous Address:

Street Address

Address Line 2

City

State

Zip Code

How long were you at this address?

Previous Address:

Street Address

Address Line 2

City

State

Zip Code

How long were you at this address?

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

Date of Birth*

Required for Commercial Drivers

Can you provide proof of age?*
YesNo

Have you worked for this company before?*
YesNo

If yes, where?

Reason for Leaving

Are you currently employed?*
YesNo

If no, how long since leaving last employment?

Who referred you?*

Rate of Pay Expected*

Have you ever been bonded?*
YesNo

If yes, name of bonding company

Employment History

Employer*

Were you subject to FMCRs while employed?*
YesNo

Reason for leaving*

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?*
YesNo

Employer*

Were you subject to FMCRs while employed?*
YesNo

Reason for leaving*

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?*
YesNo

Employer

Were you subject to FMCRs while employed?*
YesNoN/A

Reason for leaving

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?*
YesNoN/A

Accidents

For the past 3 years (if none, write none)

Experience and Qualifications - Driver

List all driver licenses or permits held in the past 3 years:

A. Have you ever been denied a license, permit, or privilege to a motor vehicle?*
YesNo

B. Has any license, permit, or privilege been suspended or revoked?*
YesNo

If the answer to either A or B is Yes, provide details

Driving Experience:

Do you have experience with a Straight Truck?*
YesNo

Check equipment type(s):
Heavy HaulTankFlatDump

Do you have experience with a Tractor and Semi-Trailer?*
YesNo

Check equipment type(s):
Heavy HaulTankFlatDump

Do you have experience with a Tractor Two-Trailers?*
YesNo

Check equipment type(s):
VanTankFlatDumpRefrid

Do you have experience with a Tractor Three-Trailers?*
YesNo

Check equipment type(s):
VanTankFlatDumpRefrid

Motorcoach-School Bus with more than 8 passengers?*
YesNo

Motorcoach-School Bus with more than 15 passengers?*
YesNo

Other vehicle experience

List states operated in over the past 5 years

Which safe driving awards to you hold from whom?

Experience and Qualifications - Other

List any trucking, transportation, or other experience that may help in your work for this company

List courses and training other than shown elsewhere in this application

Education

Highest grade level completed (high school, college)

Last school attended and location (city & state)

To be read and accepted by the applicant

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.

Please note, you must check the box below in order to be able to submit your application:

I accept

I (Name) accept the terms above.

First Name*

Last Name*

MVR Consent Form

I, (state your name),

First Name*

Middle Initial*

Last Name*

authorize Park Construction or its designated representative(s) to obtain information regarding my driving record in any state at any time while I am employed by (or seeking employment with) the company. I understand that any misstatement of the facts on this form nay be grounds for termination of employment. In the event that my MVR indicates that I am a "High Risk Driver" as defined in the glossary of the Fleet Safety Program, I understand that I may be subject to dismissal or company driving privilege suspended or revoked.

Is the information above correct?*
I certify that it is accurate and correct information

First Name*

Last Name*

Today's Date*

Federal and state laws and regulations prohibit discrimination in employment because of race, color, sex, religion, national origin, age, ancestry, creed, affectional preference, marital status, sexual orientation, status with regard to public assistance, physical or mental handicap, or disabled veteran status.

Affirmative Action Survey

As an employer/government contractor, we must comply with government regulations and affirmative action responsibilities. The information requested below will be used to determine if our recruitment efforts are reaching all segments of the community and will meet our reporting requirements. The information will be used and kept confidential in accordance with the applicable laws and regulations, including those that require the information to be summarized and reported to the Federal Government for Civil Rights enforcement. When reported, the data will not identify any specific individual. This information is voluntary.

First Name

Middle Initial

Last Name

Check one:
MaleFemaleI choose not to declare

Ethnicity
African-AmericanAmerican Indian/Native AlaskanAsian/Pacific IslanderCaucasianHispanicMore than oneI choose not to declare

Definitions of race/ethnic categories:

• Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

• White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

• Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.

• Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

• Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

• American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

• Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

Voluntary Self-Identification of Disability
Yes, I have a disability, or have had one in the pastNo, I do not have a disability and have not had one in the pastI choose not to declare

How do you know if you have a disability?

A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:

• Alcohol or other substance use disorder (not currently using drugs illegally)

• Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS

• Blind or low vision

• Cancer (past or present)

• Cardiovascular or heart disease

• Celiac disease

• Cerebral palsy

• Deaf or serious difficulty hearing

• Diabetes

• Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders

• Epilepsy or other seizure disorder

• Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome

• Intellectual or developmental disability

• Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD

• Missing limbs or partially missing limbs

• Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports

• Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)

• Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities

• Partial or complete paralysis (any cause)

• Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema

• Short stature (dwarfism)

• Traumatic brain injury

Military Veteran (select all that apply)
Not a VeteranRecently Separated VeteranVietnam Era VeteranWar/Campaign/Expedition VeteranArmed Forces Service Medal VeteranI choose not to declare

Military Branch and Rank

Referral Source (select all that apply)
Employment AgencyCommunity AgencyNewspaper AdOnline ApplicationPark EmployeeJob ServiceCollege RelationsRehireUnion Hall

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