Personal Information

Position(s) applied for: *

Last Name: *

First Name: *

Middle Name:

Email: *

List your addresses of residency for the past three years:

Current Address

Street Address: *

City: *

State: *

Zip Code: *

Telephone: *

How long have you lived here?: *

Previous Addresses

Street Address:

City:

State:

Zip Code:

How long did you live here?:

Street Address:

City:

State:

Zip Code:

How long did you live here?:

Street Address:

City:

State:

Zip Code:

How long did you live here?:


Basic Employment Information

Do you have the legal right to work in the United States? *
YesNo

Date of Birth (required for Commercial Drivers):

Can you provide proof of age? *
YesNo

Have you worked for Renaissance Nutrition before? *

Where?:

Date from:

Date to:

Rate of pay:

Position:

Reason for leaving:

Are you now employed? *

If not, how long since leaving last employment?

Who referred you?

Expected rate of pay:

Have you ever been bonded? (answer only if a job requirement) *

Name of bonding company:

Is there any reason you might be unable to perform the functions of the job for which you have applied (as defined in the job description)?

If yes, explain if you wish:

Employment History

All driver applicants driving in interstate commerce must provide the following information on all employers during the preceding three years. List complete mailing address, street number, city, state, and zip code.

Applicants to drive a commercial motor vehicle1 in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.

Note: Provide information on your past three employers starting with the most recent.

Employer

Business Name:

Address:

City:

State:

Zip Code:

Contact Person:

Phone Number:

Were you subject to the FMCSRs2 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?

Dates you were employed (mm/yy): from: to

Position Held:

Salary/Wage:

Reason for leaving:

Business Name:

Address:

City:

State:

Zip Code:

Contact Person:

Phone Number:

Were you subject to the FMCSRs2 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?

Dates you were employed (mm/yy): from: to

Position Held:

Salary/Wage:

Reason for leaving:

Business Name:

Address:

City:

State:

Zip Code:

Contact Person:

Phone Number:

Were you subject to the FMCSRs2 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?

Dates you were employed (mm/yy): from: to

Position Held:

Salary/Wage:

Reason for leaving:

Business Name:

Address:

City:

State:

Zip Code:

Contact Person:

Phone Number:

Were you subject to the FMCSRs2 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?

Dates you were employed (mm/yy): from: to

Position Held:

Salary/Wage:

Reason for leaving:

Business Name:

Address:

City:

State:

Zip Code:

Contact Person:

Phone Number:

Were you subject to the FMCSRs2 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?

Dates you were employed (mm/yy): from: to

Position Held:

Salary/Wage:

Reason for leaving:

Business Name:

Address:

City:

State:

Zip Code:

Contact Person:

Phone Number:

Were you subject to the FMCSRs2 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?

Dates you were employed (mm/yy): from: to

Position Held:

Salary/Wage:

Reason for leaving:

Business Name:

Address:

City:

State:

Zip Code:

Contact Person:

Phone Number:

Were you subject to the FMCSRs2 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?

Dates you were employed (mm/yy): from: to

Position Held:

Salary/Wage:

Reason for leaving:

Business Name:

Address:

City:

State:

Zip Code:

Contact Person:

Phone Number:

Were you subject to the FMCSRs2 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?

Dates you were employed (mm/yy): from: to

Position Held:

Salary/Wage:

Reason for leaving:

Business Name:

Address:

City:

State:

Zip Code:

Contact Person:

Phone Number:

Were you subject to the FMCSRs2 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?

Dates you were employed (mm/yy): from: to

Position Held:

Salary/Wage:

Reason for leaving:

Business Name:

Address:

City:

State:

Zip Code:

Contact Person:

Phone Number:

Were you subject to the FMCSRs2 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?

Dates you were employed (mm/yy): from: to

Position Held:

Salary/Wage:

Reason for leaving:

Business Name:

Address:

City:

State:

Zip Code:

Contact Person:

Phone Number:

Were you subject to the FMCSRs2 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?

Dates you were employed (mm/yy): from: to

Position Held:

Salary/Wage:

Reason for leaving:

1 Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding. back ^

2 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 VGWR 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. back ^

Accident Record

Accident record for the past three years or more. If none, enter NONE.

Last accident:

Nature of accident (head-on, rear-end, upset, etc.):

Fatalities:

Injuries:

Hazardous material spill:

Last accident:

Nature of accident (head-on, rear-end, upset, etc.):

Fatalities:

Injuries:

Hazardous material spill:

Last accident:

Nature of accident (head-on, rear-end, upset, etc.):

Fatalities:

Injuries:

Hazardous material spill:

Traffic Convictions

Traffic convictions and forfeitures for the past three years (other than parking violations). If none, enter NONE.

Location:

Date:

Charge:

Penalty:

Location:

Date:

Charge:

Penalty:

Location:

Date:

Charge:

Penalty:

Experience and Qualifications - Driver

Driver licenses or permits held in the past three years.

State:

License Number:

Class:

Endorsements:

Expiration date:

State:

License Number:

Class:

Endorsements:

Expiration date:

State:

License Number:

Class:

Endorsements:

Expiration date:

State:

License Number:

Class:

Endorsements:

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, give details:

Driving Experience

Straight Truck

Type of Equipment

Dates (mm/yy): from: to

Approximate number of miles:

Straight Truck

Type of Equipment

Dates (mm/yy): from: to

Approx. number of miles:

Straight Truck

Type of Equipment

Dates (mm/yy): from: to

Approx. number of miles:

Straight Truck

Type of Equipment

Dates (mm/yy): from: to

Approx. number of miles:

Straight Truck

Dates (mm/yy): from: to

Approx. number of miles:

Straight Truck

Dates (mm/yy): from: to

Approx. number of miles:

Other

Dates (mm/yy): from: to

Approx. number of miles:

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?:

Experience and Qualifications - Other

Show any trucking, transportation, or other experience that may help in your work for this company:

List courses and training:

List special equipment or technical materials you can work with (other than those already shown):

Education

High School Attended:

Highest grade level:

College Attended:

Years Attended:

Trade School Attended:

Years Attended:



I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal (Your initials) *

Name *

Date *