Employment Application

EMPLOYMENT APPLICATION & AUTHORIZATION TO RELEASE RECORDS

First Name

Last Name

Email Address

Phone #

Street Address

Street Address Line 2

City, State, Zip Code

Social Security Number

Date Available

Desired Rate of Pay

Are you a citizen of the United States?

Yes
No

If no, are you authorized to work in the U.S.?

Yes
No

Have you ever worked for this company?

Yes
No

If so, please list dates of employment with this company.

Have you ever been convicted of a felony?

Yes
No

If yes, explain:

________________________________________________________________________________________________________

EDUCATION

High School Name, City, State:

Graduation Date:

College Name, City, State:

Graduation Date:

Degree:

Other Education?

Graduation Date/Degree:

_________________________________________________________________________________________________________

MILITARY SERVICE

Have you served in the military?

Yes
No

Are you currently active in the military?

Yes
No

_________________________________________________________________________________________________________

PREVIOUS THREE YEARS RESIDENCY

Full Address:

Dates of Residence:

Full Address:

Dates of Residence:

Full Address:

Dates of Residence:

_________________________________________________________________________________________________________

DRIVER EXPERIENCE & QUALIFICATIONS

State / License Number / Type / Expiration Date

State / License Number /Type / Expiration Date

State / License Number / Type / Expiration Date

Have you driven Straight Truck?

Yes
No

If yes, list Type of Equipment (tank, flat, van, etc.) / Dates (from/to) / Approximate Number of Miles

Have you driven Tractor and Semi-Trailer?

Yes
No

If yes, list Type of Equipment / Dates / Approximate Number of Miles

Have you driven Tractor with Two Trailers?

Yes
No

If yes, list Type of Equipment / Dates / Approximate Number of Miles

List Other Types of Equipment / Dates / Approximate Number of Miles

Traffic Convictions and Forfeitures for the past 3 years (other than parking violations):

Location / Date / Charge / Penalty

Location /Date / Charge / Penalty

Location / Date / Charge / Penalty

Accident Record for the past 5 years:

Date / Nature of Accident (head-on, rear-end, rollover, etc.)

# of fatalities in this accident

# of injuries in this accident

Chemical Spills?

Yes
No

Date / Nature of Accident (head-on, rear-end, rollover, etc.)

# of fatalities in this accident

# of injuries in this accident

Chemical Spills?

Yes
No

Date / Nature of Accident (head-on, rear-end, rollover, etc.)

# fatalities in this accident

# of injuries in this accident

Chemical Spills?

Yes
No

Date / Nature of Accident (head-on, rear-end, rollover, etc.)

# of fatalities in this accident

# of injuries in this accident

Chemical Spills?

Yes
No

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

Yes
No

If yes, explain:

Has any license, permit, or privilege ever been suspended or revoked?

Yes
No

If yes, explain:

________________________________________________________________________________________________________

PREVIOUS EMPLOYMENT

Company:

Supervisor:

Phone Number:

Address:

Position Held / Dates (from/to) / Salary:

Responsibilities:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer?

Yes
No

Was this job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes
No

Company:

Supervisor:

Phone Number:

Address:

Position Held / Dates (from/to) / Salary:

Responsibilities:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer?

Yes
No

Was this job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes
No

Company:

Supervisor:

Phone Number:

Full Address:

Position Held / Dates (from/to) / Salary:

Responsibilities:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer?

Yes
No

Was this job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes
No

Company:

Supervisor:

Phone Number:

Full Address:

Position Held / Dates (from/to) / Salary:

Responsibilities:

Reason for leaving:

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer?

Yes
No

Was this job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes
No

__________________________________________________________________________________________________________

REFERENCES

Please provide three professional references.

Reference #1 Full Name:

Professional Relationship to You (e.g. Supervisor):

Company:

Phone Number:

Full Address:

Reference #2 Full Name:

Professional Relationship to You:

Company:

Phone Number:

Full Address:

Reference #3 Full Name:

Professional Relationship to You:

Company:

Phone Number:

Full Address:

________________________________________________________________________________________________________

I UNDERSTAND AND AGREE THAT:

The information supplied was submitted by myself, and all information is true and correct, to the best of my knowledge.

I understand that false or misleading information given in my application and/or interview(s) will be considered as cause for possible dismissal and/or discharge.

I also understand that I am to abide by all rules and regulations of EasTex Tower, Inc.

EasTex Tower, Inc. has my authorization to thoroughly investigate my work and personal history.

I understand that the information supplied by me regarding my: Employment History, Education (including an authorization to release transcripts), Credit History, and Criminal History will be utilized as part of the processing procedures.

I understand that the information supplied by me, regarding Medical and Professional Licensing, Motor Vehicle Records, Residence History, and References, will be used as part of the processing procedures.

I understand that a background check will be conducted to verify the veracity of the information submitted and will be utilized to develop information concerning my character, general reputation, personal characteristics, and mode of living.

I will hold no person liable for giving or receiving information in this investigation. I hereby authorize TC LogiQ, an agent of EasTex Tower, Inc., to make a thorough check of my past employment, education, and activities.

I release from liability all persons, companies, and corporations supplying that information.

I release and indemnify EasTex Tower, Inc. and TC LogiQ against any liability that might result from making such background checks. A copy of this form is as valid as the original.

I authorize EasTex Tower, Inc. to conduct a Motor Vehicle Record Check and I understand that in obtaining such reports, a consumer reporting agency may be used and I do hereby authorize such use.

I further acknowledge and agree that the reports may be procured by EasTex Tower, Inc. insurance carrier to provide an assessment of my insurability under EasTex Tower, Inc. insurance coverages.

This Authorization is pursuant to the terms and conditions under the Fair Credit Reporting Act.

Nothing on this application is intended to create or imply employment; if hired the employee understands that employment is at will, and is not for a specific time, and can be terminated at will.

The information in this form is not used in any manner considered discriminatory under EEOC guidelines.

EasTex Tower, Inc. considers applications without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

Signature:

Date:

Employment Application

Contact Us

Colorado Headquarters: 719-632-8822

Texas Office: 903-234-9370

Oklahoma Office: 405-753-6100

Folks we work with