ONLINE JOB APPLICATION

Fields marked with * are required fields.

DATE*

Position Applied For*
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NAME*:
First:

Last:

ADDRESS*:

Street Address

Address Line 2

City

State

Zip/Postal

Country
Country-oneCountry-twoCountry-three

PHONE*:

SOCIAL SECURITY NUMBER*:

HAVE YOU BEEN CONVICTED OF A FELONY IN THE LAST 7 YEARS?*

 Yes No

Conviction will not necessarily disqualify applicant from employment.

IF YES, PLEASE EXPLAIN:

STATE DRIVERS LICENSE NUMBER:

ISSUE DATE:

EXPERIATION DATE:

CDL ENDORSMENTS:

MEDICAL CARD?

EXPERIATION DATE:

REFERENCES

Please list references that are not related to yourself.

REFERENCE #1 NAME
NAME:
First:

Last:

REFERENCE #1 PHONE:

REFERENCE #2 NAME

NAME:
First:

Last:

REFERENCE #2 PHONE:

REFERENCE #3 NAME

NAME:
First:

Last:

REFERENCE #3 PHONE:

EMPLOYMENT EXPERIENCE

Start with your present or last job.

*List all types of equipment operated including trucks, truck tractors, semi trailers, full trailers, and types of
construction equipment. Indicate the nature of the work performed and the number of years or months operated.

EMPLOYER #1

EMPLOYER:

PHONE:

ADDRESS:

Street Address

Address Line 2

City

State

Zip/Postal

Country
Country-oneCountry-twoCountry-three

JOB TITLE:

SUPERVISOR:
First:

Last:

REASON FOR LEAVING:

WORK PERFORMED & EQUIPMENT OPERATED:

WERE YOU SUBJECT TO FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHITE EMPLOYED?

 Yes No

WERE YOU SUBJECT TO DOT- REQUIRED DRUG AND ALCOHOL TESTING REQUIREMENTS?

 Yes No

DATE EMPLOYED FROM:

DATE EMPLOYED TO:

STARTING HOURLY RATE / SALARY:

FINAL HOURLY RATE / SALARY:

EMPLOYER #2

EMPLOYER #2

PHONE:

ADDRESS:

Street Address

Address Line 2

City

State

Zip/Postal

Country
Country-oneCountry-twoCountry-three

JOB TITLE:

SUPERVISOR:
First:

Last:

REASON FOR LEAVING:

WORK PERFORMED & EQUIPMENT OPERATED:

WERE YOU SUBJECT TO FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHITE EMPLOYED?

 Yes No

WERE YOU SUBJECT TO DOT- REQUIRED DRUG AND ALCOHOL TESTING REQUIREMENTS?

 Yes No

DATE EMPLOYED FROM:

DATE EMPLOYED TO:

STARTING HOURLY RATE / SALARY:

FINAL HOURLY RATE / SALARY:

APPLICANT'S STATEMENT

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 investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision and release Selland Construction, from any and all liability concerning collection and use of information. In accordance with the regulations of the Motor Carrier Safety Administration, the information contained in this application may be used and the applicant?s previous employers will be contacted for the purpose of investigating the applicant?s safety performance history information. I understand that this application is not and is not intended to be a contract of employment.

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.

Select "I Agree*" below if you agree with the above statement.

 I AGREE I DO NOT AGREE