List the name, address, and telephone number of three business/work references.
Start with your most recent or present employer, and provide all employers leaving no gaps in your work
history for the last 3 places of employment. Include any military service assignments that may cause a gap.
Employer #1
Work performed / Job Duties:
Were you subject to the FMCSR while employed?**:
Yes
No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?:
Yes
No
**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weights or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Employer #2
Work performed / Job Duties:
Were you subject to the FMCSR while employed?**:
Yes
No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?:
Yes
No
**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weights or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Employer #3
Work performed / Job Duties:
Were you subject to the FMCSR while employed?**:
Yes
No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?:
Yes
No
**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weights or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
May we contact the employers you have listed?:
Yes
No
If no, indicate which one(s) you do NOT wish to us to contact and state the reasons why you prefer that we do not contact the employer(s):
Have you ever been discharged or asked to resign from any position?:
Yes
No
If yes, please state the employer and dates of employment, and reasons.:
Applicant's Statement
Please indicate that you have read and understand each paragraph of the following Applicant’s Statement by placing your initials beside each paragraph.
Initial Here:
You must enter your initials to submit.
7. I understand that this application is not, and is not intended to be, a contract of employment and if I am hired, my employment is for no fixed period of time and either I or Troyers can end the relationship at any time and for any reason. I further agree, if employed, to follow all rules, policies and regulations of Troyers I understand and agree that Troyers officials may search my property while I am, or the property is, on Troyers’s premises. I further understand that
statements contained in rules, policies, handbooks or other material do not create any guarantee of employment and that Troyers has the right to modify, amend or terminate rules, policies, handbooks or other programs within the limits and requirements imposed by law. I understand that no representative of Troyers other than the President has the authority to enter into any employment agreement for any specific period of time or to make any agreement contrary to the foregoing and that any such agreement must be in writing to be binding.
NOTE: An Application not completed in its entirety will not be considered. Please look over the entire form to make sure you have responded to every item.