Creative Travel Management

522 E. Dunlap

Phoenix, AZ 85020

APPLICATION FOR EMPLOYMENT

Applicant: READ AND SIGN BEFORE SUBMITTING THIS APPLICATION

I understand that the information in this application will be used and that prior employers will be contacted for purposes of investigation as required by 391.23 of the Motor Carrier Safety Regulations.

____________________________________________________________ _____________________________

Signature of Applicant Date

Name_____________________________________________________ Telephone____________________

(First) (Middle) (Last) Cell Phone___________________

Address____________________________________________________ How Long?___________________

(Street) (City) (State & ZIP Code)

Address____________________________________________________ How Long?___________________

(Street) (City) (State & ZIP Code)

(ATTACH SHEET IF MORE SPACE IS NEEDED)

Social Security # ________________________ Date of Birth___________________

Are you a citizen of the United States? Y/N If no, do you possess a valid work permit? Y/N

In case of emergency, notify ______________________________________________________________________________

(Name-Please Print) (Address) (Telephone)

Position applied for____________________________________ (circle one) Temporary Permanent

Have you worked for this company before? Y/N Where?________________________________________

Dates: From ____________ To ______________ Rate of pay___________ Position________________________

Names of relatives in our employ___________________________________________________________________________

Are you employed now? Y/N If not, how long since leaving last employment?_______________________________

Who referred you to us?_________________________________ Rate of pay expected_____________________________

EDUCATION

Circle highest grade completed: 1 2 3 4 5 6 7 8 High School: 1 2 3 4 College: 1 2 3 4

Name of last school attended________________________________________ City & State _____________________

GENERAL

Have you ever been bonded? Y/N Name of Bonding Company______________________________

Have you ever been refused bond? Y/N If yes, why?____________________________________________

Have you ever been convicted of any crime or felony? Y/N _____________________________________________

(Conviction of a crime will not automatically result in the declination of employment)

Have you ever worked for this company under another name? Y/N If yes, what name______________________

Date of last DOT physical examination?_________________________________________________________________

EMPLOYMENT RECORD (Attach sheet if more space is needed)

Note: DOT requires that employment for at least 3 years be shown, and names and addresses of applicant’s employers during the 7 years preceding the 3 years for which the applicant was an operator of a commercial motor vehicle, together with dates of employment and reasons for leaving such employment.

Last Employer Company/Name__________________________________________________________ Address_________________________________________________________ Telephone ________________________

Position Held_______________ From_________________ To_____________ Salary____________________

Reason(s) for Leaving_________________________________________________________________________________

Previous Employer Company/Name_____________________________________________________________________________

Address_________________________________________________________ Telephone ________________________

Position Held_______________ From_________________ To_____________ Salary____________________

Reason(s) for Leaving_________________________________________________________________________________

Previous Employer Company/Name_____________________________________________________________________________

Address_________________________________________________________ Telephone ________________________

Position Held_______________ From_________________ To_____________ Salary____________________

Reason(s) for Leaving_________________________________________________________________________________

Previous Employer Company/Name_____________________________________________________________________________

Address_________________________________________________________ Telephone ________________________

Position Held_______________ From_________________ To_____________ Salary____________________

Reason(s) for Leaving_________________________________________________________________________________

Previous Employer Company/Name_____________________________________________________________________________

Address_________________________________________________________ Telephone ________________________

Position Held_______________ From_________________ To_____________ Salary____________________

Reason(s) for Leaving_________________________________________________________________________________

Previous Employer Company/Name_____________________________________________________________________________

Address_________________________________________________________ Telephone ________________________

Position Held_______________ From_________________ To_____________ Salary____________________

Reason(s) for Leaving_________________________________________________________________________________

Previous Employer Company/Name_____________________________________________________________________________

Address_________________________________________________________ Telephone ________________________

Position Held_______________ From_________________ To_____________ Salary____________________

Reason(s) for Leaving_________________________________________________________________________________

EXPERIENCE AND QUALIFICATIONS – DRIVER

(List all licenses held for preceding 3 years)

DRIVER LICENSES

State

License No.

Type

Expiration Date

Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Y/N

Has any license, permit, or privilege ever been suspended or revoked? Y/N

IF THE ANSWER TO EITHER OF THE ABOVE QUESTIONS IS YES, ATTACH STATEMENT GIVING DETAILS.

DRIVING EXPERIENCE

Class of Equipment	Type of Equipment (Van, Tank, Flat, Etc.)	DATES From	DATES To	Approx. # of Miles Total
Straight Truck
Tractor & Semi-Trailer
Tractor – Two Trailers
Other

List states operated in for last five years:_________________________________________________________________________

List special courses or training that will help you as a driver: _______________________________________________________

___________________________________________________________________________________________________________

Which safe driving awards do you hold and from whom? __________________________________________________________

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (Attach sheet if more space is needed)

Dates	Nature of Accident (Head-On, Rear-End, Upset, Etc.)	Fatalities	Injuries
Last Accident
Next Previous
Next Previous

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (Other than parking violations)

Location

Date

Charge

Penalty

Creative Travel Management

522 E. Dunlap

Phoenix, AZ 85020

TO BE READ AND SIGNED BY APPLICANT

It is agreed and understood that any misrepresentations of information given above shall be considered an act of dishonesty and sufficient cause for dismissal.

It is agreed and understood that the employer or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his/her furnishing of such information.

The applicant agrees to furnish such additional information and complete such examinations as may be required to complete his/her employment file.

It is agreed and understood that this application for employment in no way obligates the employer to employ the applicant.

It is agreed and understood that if hired, the employee may be on a probationary period during which time he/she may be discharged without recourse.

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.

Date _________________________________ Applicant’s Signature ________________________________________