Central Refrigerated Service, Inc. – DRIVER QUALIFICATION
Name (Last)________________________________, (First)________________________, (Middle)________________________ Address __________________________________________________________________________________________________ City _________________________________, State __________, Zip ________________, Phone _________________________ Mailing Address ( if different than above) _____________________________________________________________________ |
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Commercial And Personal Driving History
Date of Birth_______/_______/________SS#___________________________Sex___________Ht.___________Wt.__________ License # _____________________________________ State where issued ___________________________________________ HAZ MAT? Yes No Do you have any OTR experience? Yes No If Yes, Explain__________________________________ # of Accidents_________________________ # of Citations_____________________ DWI or DUI Yes No Reckless Yes No Has your license been suspended? Yes No List all licenses held (states)_____________________________________________ Have you ever been arrested or convicted of a Felony? Yes No Misdemeanor? Yes No If yes, date(s) convicted_____________ |
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Employment Record ( STUDENTS , last 3 years – EXPERIENCED , last 10 years)
1. Current or Last Employer (If current employer, may we contact them? Yes No) Employer's Name _____________________________________________________Employed from ____/____ to ____/_________ Employer's Address _________________________________________________ Phone # _________________________________ Job Responsibilities _________________________________________________________________________________________ If no longer employed, state the reason for leaving _______________________________________________________________ 2. Second to Last Employer Employer's Name _____________________________________________________Employed from ____/____ to ____/_________ Employer's Address _________________________________________________ Phone # _________________________________ Job Responsibilities _________________________________________________________________________________________ Reason for Leaving __________________________________________________________________________________________ 3. Third to Last Employer Employer's Name _____________________________________________________Employed from ____/____ to ____/_________ Employer's Address _________________________________________________ Phone # _________________________________ Job Responsibilities _________________________________________________________________________________________ Reason for Leaving __________________________________________________________________________________________ 4. Fourth to Last Employer Employer's Name _____________________________________________________Employed from ____/____ to ____/_________ Employer's Address _________________________________________________ Phone # _________________________________ Job Responsibilities _________________________________________________________________________________________ Reason for Leaving ___________________________________________________________________________________________ 5. Fifth to Last Employer Employer's Name _____________________________________________________Employed from ____/____ to ____/_________ Employer's Address _________________________________________________ Phone # _________________________________ Job Responsibilities _________________________________________________________________________________________ Reason for Leaving __________________________________________________________________________________________ 6. Any periods of unemployment? If yes, when? ______________________________________________________________ |
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Authorization & Release. I authorize Central Refrigerated Service, Inc. and/or its agents, includingIs there any reason that prevents you from loading/unloading? Yes No If Yes, Explain______________________
Personal Reference ____________________________________Phone # ________________________________
Personal Reference ____________________________________Phone # ________________________________
School Location _____________________________________________________________________________
Graduation Date ________________ School Phone # ____________________ School Fax # ________________