D19transportation

Application for Employment

D19 Transportation Service, Inc. is an equal, opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.

Name:

Date:

Address:

Telephone Number:

Email Address:

Are you 23 years of age or older?

Yes

Are you either a U.S. citizen or an alien authorized to work in the U.S.?

Yes

Do you have a valid Driver’s License with Zero Points?

Yes

Position Desired

Position:

Start date available:

Wage rate desired: $

Hourly

Monthly

Annually

Do you prefer:

Full-time

Part-time

If part-time, hours per week desired:

Hours you are available to work:

Days of week you are available to work:

Are you able to work:

Weekends

Holidays

Nights

How did you learn about this opening?

Education

High School:	Graduated? Yes No	Course of Study:
Technical School:	Graduated? Yes No	Course of Study:
College/University:	Graduated? Yes No	Course of Study:
Other education, training or special skills:

Professional License or Membership

Type of License(s) Held:	State of Virginia License Number
License Expiration Date:	Other Professional Memberships:

(You need not disclose membership in professional organizations that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry, age, disability, marital status, veteran status or any other protected status)

Record of Conviction:

During the last ten years, have you ever been convicted of a crime other than minor traffic offense?

Yes

If yes, explain:

(A conviction will not necessarily automatically disqualify you for employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.)

Work Experience

Please list all previous employment, beginning with the most recent
Employer:	Address:
From To	Position Held:	Reason for Leaving:
Supervisor's Name & Title:		May we contact? Yes No
Description of Duties:
Starting Compensation:	Final Compensation:
Employer:	Address:
From To	Position Held:	Reason for Leaving:
Supervisor's Name & Title:		May we contact? Yes No
Description of Duties:
Starting Compensation:	Final Compensation:
Employer:	Address:
From To	Position Held:	Reason for Leaving:
Supervisor's Name & Title:		May we contact? Yes No
Description of Duties:
Starting Compensation:	Final Compensation:

References

Identify three persons who know your work, beginning with the most recent.

Name:

Phone Number:

Email:

Address:

City:

State:

Position or Title:

Years Known:

Name:

Phone Number:

Email:

Address:

City:

State:

Position or Title:

Years Known:

Name:

Phone Number:

Email:

Address:

City:

State:

Position or Title:

Years Known:

Upload Drivers Record:

APPLICANT'S CERTIFICATION AND AGREEMENT

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize D19 Transportation Service, Inc. to verify their accuracy and to obtain reference information on my work performance. I hereby release D19 Transportation Service, Inc. from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information.

I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.

I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the Employer. However, I further understand that neither the policies, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract.

I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause.

Put signature below,

Date