Reilley Trucking Shop Maintenance Application

Thank you for your interest in working for Reilley Trucking INC.

Please fill out the application below.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Date of Birth

YYYY

Social Security Number

Phone Number

(###)

###

####

Cell Phone Number

(###)

###

####

List any additional addresses you have lived at in the last 3 years

ID or DL Issuing State

License Number

Expiration Date

YYYY

Last Employer:

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Position Held

From

YYYY

Salary

Reason for Leaving

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES AND REASON.

Second Last Employer

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Position Held

From

YYYY

Salary

Reason for Leaving

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES AND REASON.

Third Last Employer

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Position Held

From

YYYY

Salary

Reason for Leaving

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES AND REASON.

In the Last 7 Years, Have You Been Convicted of Any Misdemeanor or Felony Offense? If So, Please Give Dates and Nature of Offense(s).

TO BE READ AND DIGITALLY SIGNED BY APPLICANT

I authorize you to make sure investigations and inquiries to my personal, employment, financial, or medical history and other related matter 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.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connectino with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Reilley Trucking. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to 1. Review information provided by current/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 I cannot agree on the accuracy of this information.

DATE

YYYY

DIGITALLY SIGN BY TYPING FULL LEGAL NAME

This Certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.