Date of Application:
First Name:
Mi. Initial:
Last Name:
Street:
Apt #:
City:
State:
Zip:
Home Phone Number:
Mobile (Cell Phone) Number:
E-mail Address:
Are you 18 years of age or older:
Date of Birth:
Do you have the legal right to live and work in the U.S.:
If hired, can you provide the documentation required by U.S. Law:
Since the age of 18, have you ever been convicted of a misdemeanor or felony?
If so, please advise nature and date:
NOTE: A conviction will not necessary disqualify you from employment. Each conviction will be judged on its own merits with respect to time, circumstance and seriousness.
Have you ever worked for this company before?
If so, please indicate when and position held:
Are You Currently Employed?
If Yes, Who is Your Current Employer:
Do you currently have a CDL?
If so, what class?
Position Sought With Selland Trucking:
List states operated in, for the last five years:
List special courses/training competed (PTD/DDC, Haz Mat, etc.):
List any Safe Driving Awards you hold and from whom:
Accident Record (Past 3 Years)
Traffic Convictions and Forfeitures for the last three years (other than parking violations)
Driver’s License (list each driver’s license held in the past three years)
Additional Information
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?:
If the answers to A, B or C is “YES”, give details:
I hereby authorize, without liability, any person or organization whose name I have given as reference, or by whom I have been previously employed or contracted with, to furnish to any recipients of this application any information they may have concerning my character, habits, ability, financial responsibility, job performance, reason for leaving employment, and all information concerning my employment. I hereby release all such persons and organizations from any claims for damages of any kind which may occur to me by reasons of furnishing such information.
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. Any false, misleading or incomplete statement of the information requested in this application shall be sufficient grounds for disqualification.
I Accept and Have Read The Terms of Application *