- Personal
- Education
- DPW
- Employment History
- Police
- Fire
- Self Identification
- General
- Attachments & Certification
High School Grade
Computer Skills (Hardware / Software)
Highest Level of Education Completed
Professional Designations
College Years
List any special skills, experience, training, licenses, or certifications you have that are relevant to the position for which you are applying, or any additional information that we should consider.
Trade Years
High School Information
College/University Information
Business Years
Vocational, Business, Other Education Information
Post-Graduated Years
Please provide the relevant information regarding your education.
Company Street
Applicant Name
If Yes, please provide the following information:
If you have completed the Return-To-Duty, documentation must be provided before any safety-sensitive transportation function is performed. Please use the attachments tab to provide the required documentation.
Company City
Have you ever had any driver license denied, revoked, or canceled by an issuing state agency?
Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous investigative information must submit a written request to the prospective employer, which may be done at anytime, including when applying or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five (5) business day deadlines will begin when the prospective employer received the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective employer may consider the driver to have waived their request to review the records.
List all traffic violations and/or convictions in the last 3 years.
State of Issuance
Employee Controlled Substance Use Statement
Attestation
As a prospective driver employee, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective employer; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
Tested Positive or Refused to Test Statement
Explanation
Company Name
List all accidents in the last 3 years.
Applicant & Company Information
Have you tested positive, or refused to test on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by the DOT agency drug and alcohol testing rules during the past two years?
Driver's License #
If yes, have you successfully completed the Return-To-Duty?
The perspective employee is required by Sec. 40.25 to respond to the following question:
Expiration Date
Company State
Signature
State
Type
Company ZIP
Traffic Accidents
Home Address Information (3-Years Worth)
I understand that as a condition of employment I must successfully complete a US DOT drug and or alcohol test as required by 49 CFR Part 655 or 49CFR Part 382 and 49 CFR Part 40 when requested by the employer. I understand that a NEGATIVE drug test is required before I will be allowed to perform safety-sensitive duties.
Pursuant to Sec. 40.25(j) of CFR 49 Part 40- An employer covered by DOT drug and alcohol testing rules must ask a perspective employee who will be performing safety-sensitive functions for said employer whether or not he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by another employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by the DOT drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test the employer must not use the employee to perform safety-sensitive functions until and unless the employee documents successful completion of the return-to-duty process. (Refer to Sec. 40.25(b)(5) and (e)).
Traffic Violations
Driver's License Information
List at least THREE people we may contact in reference to your application.
Personal References
Employment History
CDL
License #
ICS-IS-100?
Date?
Operators
Date?
ICS-IS-200?
Issuing Agency?
Date?
Driver's License Information
Endorsement?
Fire Operations
If not, do you have a current Firefighter 2 Certification that is issued by a Pro-Board or IFSAC agency?
Do you have Haz Mat Operations?
If Applying Job that may use Municipal Vehicle
Do you have a VT State Fire Academy Pro-Board Firefighter 2 certification?
License Type
Date of Certificate?
Expiration Date
ICS-IS-700?
Date of Certificate?
Date of Certificate?
Employee Signature
Any Additional information
Individual with disability is someone who:
1) has a physical or mental impairment that substantially limits one or more major life activities;
2) has a record of such impairment;
3) is regarded as having such impairment.
Signature
American Indian / Alaskan Native
White
Prefer not to answer
Native Hawaiian or Other Pacific Islander
Black or African American
Do you have a disability?
Gender (Optional)
Asian
Race/Ethnicity (Optional)
Hispanic or Latino
- White - A person having origins in any of the original peoples of Europe, North America and the Middle East.
- Black or African American - A person having origins in any of the black racial groups of Africa.
- Hispanic or Latino - All persons of Cuban, Mexican, Puerto Rican, South or Central American, or any other Spanish Culutre or origin regardless of race.
- Asian - 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.
- Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
- American Indian / Alaskan Native - All persons having origins in any of the original peoples of North America and who maintain cultural identificiations through tribal affiliation or community reconigition.
Disability (Optional)
Which employer not to be contacted?
Why should they not be contacted?
Will you be able to perform the essential job functions for the position you are applying for with or without reasonable accommodation? (Ask to see job description if one is not provided.)
Accommodations requested
General Questions
If hired, will you be able to work overtime?
Read Certification / Guidelines across all sections?
- Attach CV / Resume
- Attach Cover Letter
Attachments
Certification
Signature
The above infromation is true and correct. I understand that the hiring process will be terminated, or in the event of my employment by the Company, I shall be subject to dismissal, if any information that I have given in this applicaton, the background release form, in any resume or interview or any part of the hiring process is false or misleading, or if I have failed to give any information herein requested, or if I have withheld relevant information, regardless of the time elapsed after discovery. I authorize the Company to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I also understand that criminal background and credit reports may be conducted in the course of the post offer, pre-employment process, and I will be required to give authorization of such reports. If employed, I will be required to provide original documents that verify my identify and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. The document(s) provided that be used for completion of Form I-9.
I hereby acknowledge that I have read and agree to the above statements.