P.O. Box 41088
Eugene, OR 97404
ph. 541-344-4930
fax: 541-344-4337
EMPLOYMENT
Please fill out application below for a position with JNB Trucking.
Personal Information
Driving Experience
Class of Equipment (Straight,tractor-trailer,dump,doubles,ect)
Type of Equipment (van,tank,flat,ect)
Dates
Total Number of Miles (approx.)
From
To
X
Accident Record For Past 3 Years or More
Date
Nature of Incident (Head-on,rear-end,ect)
Fatalities
Injuries
X
Traffic Citations For Past 3 Years
Date
Location
Charge
Penalty
X
A. Have you ever been denied a license, permit, or priviledge to operate a motor vehicle?
Yes No
B. Has any license, permit, or privilege ever been suspeneded or revoked?
Yes No
C. In the last 3 years have you tested positive or refused to test on any preemployment drug or alcohol test given by another employer?
Yes No
D. Have you ever been convicted of felony?
Yes No
Employment History Note: DOT requires that employment for at least 3 years and/or commercial experience for last 10 years be shown
Last Employer
Contact Name/Phone
Address
Position Held
From
To
Wage
Reason For Leaving
Any Gaps in employment and/or unemployment must be explained.
Dates
Were you subject to the Federal Motor Carrier safety regulations while employed at ths previous employer?
Yes No
Was the previous job position designated as a safety sensitive function in an DOT regulated mode, subject to alochol and controlled substances testing required by 49 CFR Part 40?
Yes No
Last Employer
Contact Name/Phone
Address
Position Held
From
To
Wage
Reason For Leaving
Any Gaps in employment and/or unemployment must be explained.
Dates
Were you subject to the Federal Motor Carrier safety regulations while employed at ths previous employer?
Yes No
Was the previous job position designated as a safety sensitive function in an DOT regulated mode, subject to alochol and controlled substances testing required by 49 CFR Part 40?
Yes No