*Last Name:
*First Name:
Middle Initial:
Address (Number & Street):
Address (cont.):
City:
State/Province:
Zip/Postal Code:
*Phone:
Email:
Position Desired:
Social Security Number:
*Are you under 18 years of age?:
Yes
No
How were you referred?:
Date able to start:
Are you able to work all shifts?:
Yes
No
In NO, when are you UNABLE to work?:
*Are you a U.S. Citizen or authorized to work legally in the United States?
Yes
No
Cities/States of residence the past 7 years:
DRIVING HISTORY
Do you have a valid driver's license?
Yes
No
Driver's license number:
State:
Class of license:
Has your driver's license been suspended or revoked in the last 3 years?:
Yes
No
If YES, give details:
How many motor vehicle accidents have you had in the past 5 years?:
MILITARY SERVICE
Branch:
Rank:
Discharge date:
Training or type of work done in miitary service:
What machines or equipment can you operate that are related to the job for which you are applying?:
EDUCATION & TRAINING
Please list all schools you attended from High School to present. Include trade and technical schools and any courses which may be relevant to your application.
Name of High School:
City & State:
Course Degree:
Dates Attended:
Name of Trade/Technical School:
City & State:
Course Degree:
Dates Attended:
Name of College:
City & State:
Course Degree:
Dates Attended:
Other Courses/Schooling (include apprenticeship):
City & State:
Course Degree:
Dates Attended:
Professional or Technical licenses (for each, list state and date):
Please describe any job-related skills or training not mentioned above:
Have you ever been fired from a job or asked to resign?:
Yes
No
WORK HISTORY
List employers in order with present employer first. Account for all periods of time. If self-employed, give firm name and business references. Work performed on a volunteer basis may be included.
Employer 1:
Address:
Start Date:
Leave Date:
Wage:
Job title:
May we contact your supervisor?:
Yes
No
Supervisor:
Phone:
Description of work:
Reason for leaving:
Employer 2:
Address:
Start Date:
Leave Date:
Wage:
Job title:
May we contact your supervisor?:
Yes
No
Supervisor:
Phone:
Description of work:
Reason for leaving:
Employer 3:
Address:
Start Date:
Leave Date:
Wage:
Job title:
May we contact your supervisor?:
Yes
No
Supervisor:
Phone:
Description of work:
Reason for leaving:
Employer 4:
Address:
Start Date:
Leave Date:
Wage:
Job title:
May we contact your supervisor?:
Yes
No
Supervisor:
Phone:
Description of work:
Reason for leaving:
Employer 5:
Address:
Start Date:
Leave Date:
Wage:
Job title:
May we contact your supervisor?:
Yes
No
Supervisor:
Phone:
Description of work:
Reason for leaving:
Are you on a layoff and subject to recall?:
Yes
No
Are you known to schools/references (prior employers) by another name? (information sought solely to facilitate reference checks):
Yes
No
If YES, what name?:
REFERENCES
Provide names of three persons not related to you, whom you have known at least one year.
Name:
Address:
Business:
Years acquainted:
Name:
Address:
Business:
Years acquainted:
Name:
Address:
Business:
Years acquainted:
CONVICTION INFORMATION
An applicant with a sealed record of entries on file with the commissioner of probation may answer "no record" to an inquiry about prior convictions of a crime. In addition, any applicant for employment may answer "no record" to an inquiry relative to all cases of delinquency or as a "child-in-need-of-services" for which no criminal prosecution resulted.
Have you ever been convicted of a felony?:
Yes
No
If YES, explain:
Have you been convicted of a misdemeanor within the past 5 years? (Do not include a first conviction for drunkeness, simple assault, speeding, minor traffic violations, affray or disturbances of the peace.):
Yes
No
If YES, explain:
I certify that the information given above is true and complete and understand that misinterpretation and/or omission of requested information will result in the rejection of this application or my discharge if discovered after employment begins. I authorize J.A. Miara Transportation, Inc. to make inquiries regarding my history and character of prior employers, schools, government agencies or individuals and hereby release such entities and individuals from all liability with respect to such inquiries.
If I am applying for a position as a driver or other safety sensitive position, I understand and agree that I may be required to take physical examinations and drug tests as a condition of employment and continuation of employment and I agree to take such tests and to release J.A. Miara Transportation, Inc., its such owners, officers, agents and employees from any claim arising in the use of such tests.
I understand that if employed, I will be an employee “at will” and may be terminated at any time, with or without cause, and with or without notice at the option of either J.A. Miara Transportation, Inc. or myself. If I am employed, I agree to abide by J.A. Miara Transportation, Inc. policies, rules and procedures and any changes thereto. I further understand that no J.A. Miara Transportation, Inc. representative other than the J.A. Miara Transportation, Inc. President, and then only in writing and signed by the President has authority to enter into any agreement for employment for any specific period of time or to make agreement contrary to the foregoing.
*Do you agree to the statement above?:
Yes
No
Date:
DISCLOSURE TO APPLICANT OR EMPLOYEE REGARDING PROCUREMENT OF A CONSUMER REPORT
This is to advise you that as a part of our employment screening process, and investigation of your background will be conducted. The investigation will be in the form of a consumer report or investigative consumer report. The reports are for the purpose of evaluating you for employment, promotion, reassignment or retention as an employee.
*Please Type Full Name:
Electronic Signature
