Fields marked with a * are required Employment Application Step 1 of 5 20% Name* First Middle Last Address* Street Address Address Line 2 City State ZIP / Postal Code Date of Birth* Date Format: MM slash DD slash YYYY Phone #*Alternate Phone #Are you a U.S. Citizen?*YesNoDo you have the legal right to work in the U.S?*YesNoList your residency for the past 3 yearsList up to two previous addresses below, if applicable.Previous Address Street Address City State ZIP / Postal Code 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EmploymentHave you worked for this company before?*YesNoAt what location did you work?Employed From Date Format: MM slash DD slash YYYY Employed To Date Format: MM slash DD slash YYYY Reason for LeavingMiscellaneousWere you referred to Golding Transport?*YesNoWho referred you?Is there any reason you might be unable to perform the functions of the job for which you have applied?*YesNoIf Yes, please elaborateEducationHighest Grade Completed*1st2nd3rd4th5th6th7th8thHigh School*9th10th11th12thCollege1st year2nd year3rd year4th yearMilitaryHave you served in the military?*YesNoBranch of ServiceType of Discharge Employment History(Attach a Separate Sheet if more space is needed)List employment for last 10 YEARS, applicants to drive commercial motor vehicles in intrastate or interstate commerce must provide 10 year information on previous employers.Are you currently employed?*YesNoHow many months since leaving last employment?Please enter a number greater than or equal to 0.Most recent Employer NameEmployed From Date Format: MM slash DD slash YYYY Employed To Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State ZIP / Postal Code Position HeldPhoneReason for LeavingWere you subject to FMCSR* while employed?YesNoWere you subject to drug/alcohol testing?YesNoSecond Employer NameEmployed From Date Format: MM slash DD slash YYYY Employed To Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State ZIP / Postal Code Position HeldPhoneReason for LeavingWere you subject to FMCSR* while employed?YesNoWere you subject to drug/alcohol testing?YesNoThird Employer NameEmployed From Date Format: MM slash DD slash YYYY Employed To Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State ZIP / Postal Code Position HeldPhoneReason for LeavingWere you subject to FMCSR* while employed?YesNoWere you subject to drug/alcohol testing?YesNoFourth Employer NameEmployed From Date Format: MM slash DD slash YYYY Employed To Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State ZIP / Postal Code Position HeldPhoneReason for LeavingWere you subject to FMCSR* while employed?YesNoWere you subject to drug/alcohol testing?YesNo* Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle that is over 10,000 lbs, is designed to transport 9 or more passengers OR is any size used to transport hazardous materials requiring placarding.Attach a RésuméIf more space is needed, feel free to attach your résumé. Drivers License Information(List all drivers license held in the previous 5 years)*StateLicense TypeExpiration Date Traffic Convictions and Forfeitures(List all in previous 3 years, other than parking. If none, then write NONE)DateChargeStatePenalty Accident Record(List all in previous 3 years. If none, write NONE)DateNature of AccidentFatalitiesInjuriesTicketed Driving Experience and QualificationsClasses of Equipment Straight Truck Tractor & Trailer Tractor w/ Doubles Tractor w/ Triples Other Type of EquipmentFromToApprox # of Miles List any trucking, transportation or other experience that may help in your work for this company:List courses and training other than listed elsewhere in this application: Have you ever had any type of motor vehicle license suspended or revoked, or ever been denied a license, permit of privilege to operate a motor vehicle?*YesNoDo you have a pending charge or past conviction for driving while intoxicated?*YesNoHave you ever been convicted of any serious misdemeanor or felony?*YesNoIf you answered yes to any of the above questions, please explain:In the two years prior to the date of the employee's signature, for DOT-regulated testing:1. Have you had an alcohol test with a result of 0.04 or higher?*YesNo2. Have you had a positive drug screen?*YesNo3. Have you refused to be tested?*YesNo4. Have you had any other violations of DOT agency drug/alcohol testing requirements?*YesNo5. Have you had a previous employer report a drug/alcohol rule violation to you?*YesNo6. If you answered "yes" to any of the above questions, did you complete the return-to-duty process?YesNoNOTE: If you answered "yes" to item 5, you must provide the previous employer's report. If you anwered "yes" to item 6, you must also transmit the appropriate return-to-duty documention (e.g, SAP report(s), follow-up testing record.)Application Addendum Federal Motor Carrier Safety Regulations 40.25(j): The employer must ask the employee whether he or she has tested positive or refused to test, on any pre-employment drug or alcohol test adminstered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. Have you tested positive or refused to test, on any pre-employment drug test or have you tested 0.02 or greater, or refused to test, on any pre-employment alcohol test during the past two years?*YesNoApplicant (Enter Full Name)*SignatureDate* Date Format: MM slash DD slash YYYY TO BE READ AND SIGNED BY APPLICANTI authorize GOLDING TRANSPORT INC. to make such investigations and inquires of my personal, employment, financial, PSP or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquires 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. This certifies that this application was completed by me, and that all the entries on it and information in it are true and complete to the best of my knowledge.Applicant (Enter Full Name)*Signature*Date* Date Format: MM slash DD slash YYYY Captcha
