Personal Information

Date

Month/Day/Year

First name*

Middle Initial*

Last name*

Local Union Membership #

Email*

Street address*

City*

State/Region*

Postal code*

Phone number*

Are You a U.S. Citizen?

Yes

Position Applying For

Position*

Desired Salary*

Referred By

Date Available

Month/Day/Year

Years of Experience in Position Applying For

Are You Currently Enrolled in a Disa Drug Testing Program?

Yes

Have You Ever Failed a Disa Drug Test?

Yes

Educational Information

Highest Level of Education Completed

Area of Study

Degree Awarded

License and Driving History Information

Driver's License State

Driver's License Number

Driver's License Type

Driver's License Expiration Date

Class of Equipment

Type of Equipment

Approximate # of Miles

Accident & Traffic Violation History

Accident #1

Accident Date

Month/Day/Year

Type of Accident

Were You at Fault?

Yes

Were There Injuries or Fatalities?

Accident #2

2nd Accident Date

Month/Day/Year

Accident #2 - Type of Accident

2nd Accident - Were You at Fault

Yes

2nd Accident - Were There Injuries or Fatalities?

Traffic Violation 1

Date of Traffic Violation 1

Month/Day/Year

Type of Traffic Violation

Location of Traffic Violation

Traffic Penalty

Traffic Violation 2

Date of Traffic Violation

Month/Day/Year

Traffic Violation 2 - Type of Traffic Violation

Traffic Violation 2 - Location of Traffic Violation

Traffic Violation 2 - Traffic Violation Penalty

Past Work Experience

1. Employer

Company name

Job 1 Start Date

Month/Day/Year

Job 1 End Date

Month/Day/Year

Reason for Leaving Job 1

Please list job duties & responsibilities for Job 1

Were you subject to the FMCSRs* while employed by this employer 1?

Yes

For Job 1, were you subject to DOT alcohol and controlled substances testing regulations?

Yes

May we contact job 1 for reference?

Yes

Job 1 Reference Phone Number

2. Employer

(2) Company Name

Job 2 Start Date

Month/Day/Year

Job 2 End Date

Month/Day/Year

Reason for Leaving Job 2

Please list job duties & responsibilities for Job 2

Were you subject to the FMCSRs* while employed by employer 2?

Yes

For Job 2, were you subject to DOT alcohol and controlled substances testing regulations?

Yes

May we contact job 2 for reference?

Yes

Job 2 Reference Phone Number

3. Employer

(3) Company Name

Job 3 Start Date

Month/Day/Year

Job 3 End Date

Month/Day/Year

Reason for Leaving Job 3

Please list job duties & responsibilities for Job 3

Were you subject to the FMCSRs* while employed by employer 3?

Yes

For Job 3, were you subject to DOT alcohol and controlled substances testing regulations?

Yes

May we contact job 3 for reference?

Yes

Job 3 Reference Phone Number

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I certify that the answers given on this application are true. I understand that my failure to answer the questions or the falsification of any statement made, may result in the rejection of my application or dismissal from employment if discovered after hiring. I also understand that I am free to resign at any time and that Deep South Crane and Rigging, LLC reserves the right to terminate my employment at any time.*