In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, martial status, or non-job related disability.
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List your address of residency for the past 3 years.
Do you have the legal right to work in the U.S.?:
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Can you provide proof of your age?:

Have you worked for Agtegra before?:

Are you currently employed?:

Were you referred for this position?:

Is there any reason you might be unable to perform the functions of the job for which you have applied for? :

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code. 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. Employment History All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code. 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.
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I was subject to FMCSA Regulations while employed here? :

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I was held a safety sensitive function that required DOT Drug & Alcohol testing as required by 49 CFR Part 40?:

Please put nature of accident. Accident record for the past 3 years or more (attach sheet if more space is needed) if none, write none.
Were there any fatalities?:

Were there any injuries?:

Please put nature of accident.
Were there any fatalities?:

Were there any injuries?:

Please put nature of accident.
Were there any fatalities?:

Were there any injuries?:

Traffic convictions and forfeitures for the past 3 years (other than parking violations) if none, write none.
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Conviction 2
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Conviction 3
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Have you ever been convicted of a crime other than petty traffic offenses?:

The existence of a criminal record will not necessarily bar an applicant from employment
Highest level of education:





List name and location
Have you ever been denied a license, permit or privilege to operate a motor vehicle?:

Has any license, permit or privilege ever been suspended or revoked?:


Do you have experience driving a Tractor & Semi Tractor:

Do you have experience driving a Tractor - Two Trailers:

Do you have experience driving a Motor Coach - School Bus:

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. I authorize you to make such investigations and inquire of my persona, 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 personas from all liability in responding to inquiries and releasing information in connections with my application. I understand that information I provided regarding current and/or previous employers may be used, and required by 49 CFR 391.23 (d) and (e). I understand that I have the right to: *Review information provided by pervious 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 employ(s) and I cannot agree on the accuracy of the information 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.
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By typing your name you agree that all information is correct.
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