Application

ON-LINE APPLICATION
PERSONAL INFORMATION
Name:
Street Address:
City:		State:	Zip:
Phone:
E-Mail Address:
Position Interested In:
Currently Employed?	Yes No
DRIVER (ONLY) INFORMATION
CDL#		State:	Exp:
Number of tickets in last 3 years:
Number of accidents in last 3 years:
Have you ever been convicted of a felony or misdemeanor?	Yes No
Have you tested positive or refused a drug or alcohol test in the last 3 years?	Yes No
EMPLOYMENT HISTORY
Present or Last_Employer:
Dates of Employment:	To:
Address:
City:		State:	Zip:
Phone:
Contact:
Previous Employer:
Dates of Employment:	To:
Address:
City:		State:	Zip:
Phone:
Contact:
Previous Employer:
Dates of Employment:	To:
Address:
City:		State:	Zip:
Phone:
Contact:
	.
By completing and submitting this application, I: • Agree and understand that the completion of this application does not constitute authorization for the application to drive, nor does it obligate in any way Thomas E. Keller Trucking, Inc. to authorize the applicant to drive. • Authorize Thomas E. Keller Trucking, Inc. to request information which may contain but is not limited to the following information: names and dates of previous employers; reason for termination of employment; work experience; accidents; etc. • Authorize Thomas E. Keller Trucking, Inc. to request Driver Information Records for Transportation Information Services, Inc., d/b/a DAC Services ("DAC") relating to your previous driver employment, including but not limited to, previous driver employment history, Motor Vehicle Record requests, Alcohol and Drug Test results, Criminal History and Insurance Claim Reports. I further understand that such information will include information from various State agencies which maintian records concerning traffic offenses, accidents, etc., as well as other information on file with DAC. • Understand and agree that I will be required to submit to and pass a drug test, as required as a condition of preemployment, and thereafter in accordance with Thomas E. Keller Trucking, Inc. policies and procedures and federal regulations. • Agree that providing false, misleading or incomplete statements in this application and/or supplemental documents in connection with Employer's evaluation of me as a candidate for employment is grounds for immediate termination of my employment, regardless of when suc information is discovered. • Certify that this application was completed by me and that all entries on it are true and complete to the best of my knowledge.