MCC, INC. - Murphy Concrete & Construction

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MCC, INC. - DRIVER'S APPLICATION FOR EMPLOYMENT
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disablity.

Position(s) Applied For:
First Name:
Middle Name:
Last Name:
Social Security Number:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ List Your Addresses Of Residency For The Past 3 Years.
Current Street Address:
Current City:
Current State:
Current Zip Code:
Current Phone Number:
How Long?
Previous Street Address:
Previous City:
Previous State:
Previous Zip:
How Long?
Previous Street Address:
Previous City:
Previous State:
Previous Zip:
How Long?
Previous Street Address:
Previous City:
Previous State:
Previous Zip:
How Long?
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Do You Have The Legal Right To Work In The United States?
Date Of Birth (Required for Commercial Drivers):
Can You Provide Proof Of Age?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Have You Worked For MCC, Inc. Before?
If Yes, Please Fill Out The Following Information.
Where?
Date Work Started At MCC, Inc.:
Date Work Ended At MCC, Inc.:
Rate Of Pay:
Position:
Reason For Leaving:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Have you ever been bonded?
If Yes, What Is The Name Of The Bonding Company?
Have you ever been convicted of a felony?
If Yes, Please Explain Fully. Conviction Of A Crime Is Not An Automatic Bar To Employment. All Circumstances Will Be Considered.
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Are You Now Employed?
If Not, How Long Since Leaving Last Employment?
Who Referred You?
Rate Of Pay Expected:
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Is There Any Reason You Might Be Unable To Perform The Functions Of The Job For Which You Have Applied [As Described In The Job Description]?
If Yes, Explain If You Wish:
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EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code. The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding. Applicants to drive a commercial motor vehicle (includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding) in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent.)
Employer Name:
Address:
City:
State:
Zip:
Contact Person
Phone Number
Month Work Started
Year Work Started
Month Work Ended
Year Work Ended
Position Held
Salary / Wage
Reason For Leaving
Were You Subject To The FMCSRs While Employed?
Was Your Job Designated As A Safety-Sensitive Function In Any DOT-Regulated Mode Subject To The Drug And Alcohol Testing Requirements Of 49 CFR Part 40?
Employer Name:
Address:
City:
State:
Zip:
Contact Person
Phone Number
Month Work Started
Year Work Started
Month Work Ended
Year Work Ended
Position Held
Salary / Wage
Reason For Leaving
Were You Subject To The FMCSRs While Employed?
Was Your Job Designated As A Safety-Sensitive Function In Any DOT-Regulated Mode Subject To The Drug And Alcohol Testing Requirements Of 49 CFR Part 40?
Employer Name:
Address:
City:
State:
Zip:
Contact Person
Phone Number
Month Work Started
Year Work Started
Month Work Ended
Year Work Ended
Position Held
Salary / Wage
Reason For Leaving
Were You Subject To The FMCSRs While Employed?
Was Your Job Designated As A Safety-Sensitive Function In Any DOT-Regulated Mode Subject To The Drug And Alcohol Testing Requirements Of 49 CFR Part 40?
Employer Name:
Address:
City:
State:
Zip:
Contact Person
Phone Number
Month Work Started
Year Work Started
Month Work Ended
Year Work Ended
Position Held
Salary / Wage
Reason For Leaving
Were You Subject To The FMCSRs While Employed?
Was Your Job Designated As A Safety-Sensitive Function In Any DOT-Regulated Mode Subject To The Drug And Alcohol Testing Requirements Of 49 CFR Part 40?
Employer Name:
Address:
City:
State:
Zip:
Contact Person
Phone Number
Month Work Started
Year Work Started
Month Work Ended
Year Work Ended
Position Held
Salary / Wage
Reason For Leaving
Were You Subject To The FMCSRs While Employed?
Was Your Job Designated As A Safety-Sensitive Function In Any DOT-Regulated Mode Subject To The Drug And Alcohol Testing Requirements Of 49 CFR Part 40?
Employer Name:
Address:
City:
State:
Zip:
Contact Person
Phone Number
Month Work Started
Year Work Started
Month Work Ended
Year Work Ended
Position Held
Salary / Wage
Reason For Leaving
Were You Subject To The FMCSRs While Employed?
Was Your Job Designated As A Safety-Sensitive Function In Any DOT-Regulated Mode Subject To The Drug And Alcohol Testing Requirements Of 49 CFR Part 40?
Employer Name:
Address:
City:
State:
Zip:
Contact Person
Phone Number
Month Work Started
Year Work Started
Month Work Ended
Year Work Ended
Position Held
Salary / Wage
Reason For Leaving
Were You Subject To The FMCSRs While Employed?
Was Your Job Designated As A Safety-Sensitive Function In Any DOT-Regulated Mode Subject To The Drug And Alcohol Testing Requirements Of 49 CFR Part 40?
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Accident Record for the past 3 years or more. If none, skip this section.
Last Accident Date:
Nature of Accident (head-on, rear-end, upset, etc.):
Fatalities:
Injuries:
Hazardous Material Spill:
Next Previous Accident Date:
Nature of Accident (head-on, rear-end, upset, etc.):
Fatalities:
Injuries:
Hazardous Material Spill:
Next Previous Accident Date:
Nature of Accident (head-on, rear-end, upset, etc.):
Fatalities:
Injuries:
Hazardous Material Spill:
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Traffic Convictions and Forfeitures for the past 3 years (other than parking violations). If none, skip this section.
Location:
Date:
Charge:
Penalty:
Location:
Date:
Charge:
Penalty:
Location:
Date:
Charge:
Penalty:
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Highest Grade Completed:
Last School Attended Name:
Last School Attended City:
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List All Driver Licenses Or Permits Held In The Past 3 Years
State:
License Number:
Type:
Expiration Date:
State:
License Number:
Type:
Expiration Date:
State:
License Number:
Type:
Expiration Date:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Has any license, permit, or privilege ever been suspended or revoked?
If the answer to either of the previous questions is yes, please explain by giving details:
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Driving Experience - Straight Truck. If none, skip this section.
Type of Equipment (Van, Tank, Flat etc.):
Starting Date:
Ending Date:
Approximate Number of Miles (Total):
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Driving Experience - Tractor and Semi-Trailer. If none, skip this section.
Type of Equipment (Van, Tank, Flat etc.):
Starting Date:
Ending Date:
Approximate Number of Miles (Total):
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Driving Experience - Tractor - Two Trailers. If none, skip this section.
Type of Equipment (Van, Tank, Flat etc.):
Starting Date:
Ending Date:
Approximate Number of Miles (Total):
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Driving Experience - Tractor - Three Trailers. If none, skip this section.
Type of Equipment (Van, Tank, Flat etc.):
Starting Date:
Ending Date:
Approximate Number of Miles (Total):
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Driving Experience - Motorcoach - School Bus (More Than 8 Passengers). If none, skip this section.
Starting Date:
Ending Date:
Approximate Number of Miles (Total):
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Driving Experience - Motorcoach - School Bus (More Than 15 Passengers). If none, skip this section.
Starting Date:
Ending Date:
Approximate Number of Miles (Total):
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Driving Experience - Other. If none, skip this section.
Type of Equipment (Van, Tank, Flat etc.):
Starting Date:
Ending Date:
Approximate Number of Miles (Total):
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List States Operated In For Last Five Years:
Show Special Courses Or Training That Will Help You As A Driver:
Which Safe Driving Awards Do You Hold And From Whom?:
Show Any Trucking, Transportation Or Other Experience That May Help In Your Work For MCC, Inc.:
List Courses And Training Other Than Shown Elsewhere In This Application:
List Special Equipment Or Technical Materials You Can Work With (Other Than Those Already Shown):
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
You are required by sec.40.25(j) to respond to the following questions.
Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?
If you answered yes, can you provide/obtain proof that you've successfully completed the DOT return-to-duty requirements?
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THIS SECTION IS COMPLETELY VOLUNTARY We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental, or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria. In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated. Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations.
Referral Source
Explain
Name of person who referred you if applicable
Sex
Please select one of the following Equal Employment Opportunity Identification Groups:
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By clicking the submit button, you agree to the following terms. This certifies that the application was completed by you, and that all entries on it and information in it are true and complete to the best of your knowledge. You authorize MCC, Inc. to make such investigations and inquiries of your personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) You hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with your application. In the event of employment, you understand that false or misleading information given in your application or interview(s) may result in discharge. You understand, also, that you are required to abide by all rules and regulations of MCC, Inc. You understand that information you provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating your safety performance history as required by 49 CFR 391.23(d) and (e). You understand that you have the right to: (1) Review information provided by previous employers; (2) Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and (3) Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and you cannot agree on the accuracy of the information. In accordance with 49 CFR 382.405(h) and 382.413(b), you authorize and request previous employer(s) to furnish to MCC, Inc., any and all information in their possession concerning your participation in a drug and alcohol testing program under 49 CFR part 382. You specifically authorize the previous employer(s) to release information on any alcohol tests with concentration results of 0.04 or greater, positive controlled substance test results, and/or refusals to be tested within two years preceding the date of this request. You further authorize and request the previous employer(s) to release any information in their possession concerning your evaluation by a substance abuse professional, the identity of that substance abuse professional, your participation in any treatment or rehabilitation recommended by the substance abuse professional and the results of any return-to-duty or alcohol test within the past two years. You hereby authorize previous employer(s) to release and forward the information requested concerning my Alcohol and Controlled Substances Testing records withing the previous 3 years in compliance with sections 40.25 and 391.23.

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