Driver Employment Application

Name*
First Middle Last
Present Address*
Street Address Address Line 2 City State ZIP Code
How long at current address:*
Social Security No.*
Telephone - Home*
Telephone - Cell*
Previous 3 Years Residency Information:*
Click the plus button to the right to add additional locations.
Number Street City State Zip Length at Address:
Are you currently authorized to work in the United States?*
Proof of eligibility will be required if hired.
- Yes
- No
Have you ever applied to Nappie's Food Service before?*
- Yes
- No
Date of Birth*
MM slash DD slash YYYY
Employment Desired:*
- Full-Time Only
- Part-Time Only
- Temporary/Seasonal
Position*
When are you available to start work?*
MM slash DD slash YYYY
Are you currently employed?*
- Yes
- No
How many hours can you work weekly?*
Education*
Please include information for any high school, college, business or trade school, or professional schooling received. Click the plus button to the right to add additional schooling.
Name of School Location Number of Years Completed Major & Degree
Have you ever been convicted of a crime?*
(A Conviction record will not necessarily disqualify you from employment.)
- Yes
- No
How did you hear about this position?*
UNDER PENNSYLVANIA LAW MOST EMPLOYERS MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, OR PROSPECTIVE EMPLOYMENT OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT.
Have you ever been in the armed forces?*
- Yes
- No
Are you now a member in the armed forces?*
- Yes
- No
Please list your military experience.*
Specialty Date Entered Discharge Date
Work Experience
All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of a ten-year employment record). Please list your work experience for the beginning with your most recent job held. If you were self-employed, give firm name. You are required to list the complete mailing address: street number and name, city, state and zip code.
Name of Current or Last Employer*
Current or Last Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Current or Last Employer Phone Number*
Current or Last Employer - Name of Last Supervisor*
First Last
Current or Last Employer - Start Date*
MM slash DD slash YYYY
Current or Last Employer - End Date*
MM slash DD slash YYYY
Current or Last Employer Position Held*
Current or Last Employer Pay or Salary (Start)*
Current or Last Employer Pay or Salary (Final)*
Current or Last Employer Reasons for Leaving (Be Specific)*
At your current or last employer, Were you subject to the Federal Motor Carrier Safety Regulations** while employed?*
**The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver) for compensation; or (3) is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
- Yes
- No
At your current or last employer, 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
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:
Second Past Employer Name
Second Past Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Second Past Employer Phone Number
Second Past Employer - Name of Last Supervisor
First Last
Second Past Employer - Start Date
MM slash DD slash YYYY
Second Past Employer - End Date
MM slash DD slash YYYY
Second Past Employer Position Held
Second Past Employer Pay or Salary (Start)
Second Past Employer Pay or Salary (End)
Second Past Employer Reasons for Leaving (Be Specific)
At your Second Past Employer, were you subject to the Federal Motor Carrier Safety Regulations** while employed?*
**The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver) for compensation; or (3) is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
- Yes
- No
At your Second Past Employer, 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
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:
Third Past Employer Name
Third Past Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Third Past Employer Phone Number
Third Past Employer Name of Last Supervisor
First Last
Third Past Employer - Start Date
MM slash DD slash YYYY
Third Past Employer - End Date
MM slash DD slash YYYY
Third Past Employer Position Held
Third Past Employer Pay or Salary (Start)
Third Past Employer Pay or Salary (Final)
Third Past Employer Reasons for Leaving (Be Specific)
At your Third Past Employer, were you subject to the Federal Motor Carrier Safety Regulations** while employed?*
**The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver) for compensation; or (3) is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
- Yes
- No
At your Third Past Employer, 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
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:
Work Qualifications
Please fill out the following based on your driving experience.
Driving Experience - If no experience driving with the past 3 years please check below.
- No driving experience within the past 3 years.
Experience with Straight Truck*
- Yes
- No
Type of Equipment
Select all that apply to your experience with Straight Trucks.
- Select All
- Van
- Reefer
- Tanker
- Flat Bed
Experience with Straight Truck (Begin Date)
MM slash DD slash YYYY
Experience with Straight Truck (End Date)
MM slash DD slash YYYY
Experience with Tractor/Semi-Trailer*
- Yes
- No
Type of Equipment
Select all that apply to your experience with Tractor/Semi-Trailer
- Select All
- Van
- Reefer
- Tanker
- Flat Bed
Experience with Tractor/Semi-Trailer (Begin Date)
MM slash DD slash YYYY
Experience with Tractor/Semi-Trailer (End Date)
MM slash DD slash YYYY
Experience with Tractor - 2 Trailers*
- Yes
- No
Type of Equipment
Select all that apply to your experience with Tractor - 2 Trailers
- Select All
- Van
- Reefer
- Tanker
- Flat Bed
Experience with Tractor - 2 Trailers (Begin Date)
MM slash DD slash YYYY
Experience with Tractor - 2 Trailers (End Date)
MM slash DD slash YYYY
Experience with Tractor - 3 Trailers*
- Yes
- No
Type of Equipment
Select all that apply to your experience with Tractor - 3 Trailers
- Select All
- Van
- Reefer
- Tanker
- Flat Bed
Experience with Tractor - 3 Trailers (Begin Date)
MM slash DD slash YYYY
Experience with Tractor - 3 Trailers (End Date)
MM slash DD slash YYYY
Do you have any Other experience with Equipment not listed?
- Yes
- No
Other (Experience):
Type of Equipment
Select all that apply to your Other experience.
- Select All
- Van
- Reefer
- Tanker
- Flat Bed
Experience with Other (Begin Date)
MM slash DD slash YYYY
Experience with Other (End Date)
MM slash DD slash YYYY
Experience with Motorcoach/School Bus (Greater than 8 Passengers)*
- Yes
- No
Experience with Motorcoach/School Bus (Greater than 8 Passengers) (Begin Date)
MM slash DD slash YYYY
Experience with Motorcoach/School Bus (Greater than 8 Passengers) (End Date)
MM slash DD slash YYYY
Experience with Motorcoach/School Bus (Greater than 15 Passengers)*
- Yes
- No
Experience with Motorcoach/School Bus (Greater than 15 Passengers) (Begin Date)
MM slash DD slash YYYY
Experience with Motorcoach/School Bus (Greater than 15 Passengers) (End Date)
MM slash DD slash YYYY
Accident History/Traffic Convictions and Forfeitures
ACCIDENT HISTORY - If no accidents while driving within the past 3 years please check below.
- No accidents while driving within the past 3 years
ACCIDENT HISTORY
Click the plus button to the right to add additional entries.
Date (Month/Year) Nature of Accident (Head-on, Rear-end, etc) Number of Fatalities Number of Injuries Hazardous Material Spill? (Yes or No)
If no traffic convictions and/or forfeitures in the past 3 years please check below.
- No traffic convictions and/or forfeitures in the past 3 years
Traffic Convictions and Forfeitures (3 Years)
Click the plus button to the right to add additional entries.
Date Convicted (Month/Year) Violation (Parking violations do not apply) State of Violation Penalty (Forfeited bond, collateral and/or points)
License Information*
Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.
State License Number Expiration Date
CDL HOLDERS: HAVE YOU EVER BEEN NON-COMPLAINT WITH ANY DOT MANDATED PRE-EMPLOYMENT DRUG OR ALCOHOL TEST WITHIN THE PAST 2 YEARS?
- Yes
- No
HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT, OR PRIVILEGE TO OPERATE A MOTOR VEHICLE?
- Yes
- No
If yes, give details:
HAS ANY LICENSE, PERMIT, OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED?*
- Yes
- No
If yes, give details:
AUTHORIZATION – TO BE READ & SIGNED BY APPLICANT
If you are to be hired by the company, you will be required to attest to your identity and employment eligibility and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements.
Authorization - Applicant Signature*
I certify that the facts contained in this application and attached resume is applicable are true and complete to the best of my knowledge. I understand that any misrepresentation or material omission made by me on this application/resume will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. I understand that any employment is conditioned on a background check. I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application and/resume from all previous employers, educational institutions, and references. I authorize my former employers and references to disclose information regarding my former employment, character and general reputation to the potential employer, without giving me prior notice of such disclosure. In addition, I release the potential employer, any former employers, schools. Health care providers and all references listed from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure. I authorize you to make such investigations and inquiries of my personal, 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.) 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 current/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.” I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions. I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be “at will” and without fixed term, and may be terminated at any time, with or without prior notice, at the option of either myself or the Company. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Company unless made in writing and so long as there is no violation of applicable federal or state law. If I am offered employment I agree to submit to a medical examination and drug test before starting work. If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by Nappies Food Service and as permitted by law. I consent to such examinations and tests and I request that the examining doctor disclose to the Company the results of the examination, which results shall remain confidential and segregated from my personnel file. I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drug test, and if I am hired a condition of my employment will be that I abide by the Company’s Drug and Alcohol Policy. We are an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age, height, weight, or disability. We assure you that your opportunity for employment with us depends solely on your qualifications. I understand that filling out this form does not indicate there is a position open and does not obligate the Company to hire. If hired, I agree to abide by all Company work rules, policies and procedures. Nappies Food Service retains the right to revise its policies or procedures, in whole or in part, at any time. Please sign below.
Print Name
Date
MM slash DD slash YYYY
THE POSITION THAT YOU ARE APPLYING FOR (TRUCK DRIVER, WAREHOUSE LABORER) REQUIRES THE PHYSICAL DEMANDS OF LIFTING AND CARRYING UP TO 100 LBS. ON AN OCCASIONAL BASIS AND 50-75 LBS. ON A FREQUENT BASIS. THIS LIFTING AND CARRYING IS REPETITIVE THROUGHOUT THE COURSE OF THE DAY AND IS AN ESSENTIAL COMPONENT OF THESE JOBS. ARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THIS JOB WITH OR WITHOUT SPECIAL ACCOMMODATIONS?*
- Yes
- No
ARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THIS JOB WITH OR WITHOUT SPECIAL ACCOMMODATIONS? Please sign below to indicate "Yes."*
THE POSITION THAT YOU ARE APPLYING FOR (TRUCK DRIVER, WAREHOUSE LABORER) REQUIRES THE PHYSICAL DEMANDS OF LIFTING AND CARRYING UP TO 100 LBS. ON AN OCCASIONAL BASIS AND 50-75 LBS. ON A FREQUENT BASIS. THIS LIFTING AND CARRYING IS REPETITIVE THROUGHOUT THE COURSE OF THE DAY AND IS AN ESSENTIAL COMPONENT OF THESE JOBS.

Name of School	Location	Number of Years Completed	Major & Degree

Date (Month/Year)	Nature of Accident (Head-on, Rear-end, etc)	Number of Fatalities	Number of Injuries	Hazardous Material Spill? (Yes or No)

Date Convicted (Month/Year)	Violation (Parking violations do not apply)	State of Violation	Penalty (Forfeited bond, collateral and/or points)

Number	Street	City	State	Zip	Length at Address:

Specialty	Date Entered	Discharge Date

Driver Employment Application

Driver Employment Application

Work Experience

Work Qualifications

Accident History/Traffic Convictions and Forfeitures

AUTHORIZATION – TO BE READ & SIGNED BY APPLICANT