form testing Employment Application Name* First Last Middle Address* Street Address Apt City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Phone*Provide at least one phone number where you can be reached.Email* Who Referred You?*SelectPeek EmployeeEmployment AgencyWalk-InNewspaperInternetOtherPosition Applying ForLocation Applying For*Columbus, GeorgiaCartersville, GeorgiaValdosta, GeorgiaLocust Grove, GeorgiaRichmond Hill, GeorgiaByron,GeorgiaSummerville, South CarolinaColumbia, South CarolinaSpartanburg, South CarolinaPlease specify the name of the Employee, Employee Agency, Newspaper Name, or Name of Internet Service/Website. If other, explain:APPLICANTS MUST READ AND SIGN BELOW I hereby authorize Fortson-Peek Company, Inc. and Peek Pavement Marking, LLC -- hereafter referred to as "Peek" -- to investigate my past employment, education, criminal background history, credit history, driving record, medical history, worker's compensation history, military service, and other matters as may be necessary in arriving at decision relating to my employment. Further, I release my previous employers, personal referees and all other responders to Peek inquiries from liabilities of damages on account having furnished information about me in good faith and in accordance with applicable laws. I understand that current and/or previous employers will be contacted for the purpose of investigating my records. In particular, I authorize Peek to seek information concerning my criminal background history, my driving history, my safety performance history, and my participation in -- and results of -- employer drug and alcohol testing (including refusals) in accordance with Federal Motor Carrier Safety Regulations (FMCSR). Accordingly, I acknowledge my consent -- with special regard to governemnt law enforcement agencies, related third party report services, and other persons or organizations holding such information about me -- to share these records with Peek, releasing them from any liability for their contributions. I acknowledge my right: 1)to review information provided by previous employers; 2) to have errors int the information corrected by previous employers and for those previous employers to resend the corrected information to the prospective employer; and 3) to have a rebuttal statement attached to the alleged erroneous information if the previous employer(s) and I cannot agree on the accuracy of the information. Should I become a Peek employee, I acknowledge the requirement of periodic inquiries into my FMCSR -- related records during and after my period of employment. Accordingly, I extend my consent and release of liability for damages regarding persons or organizations involved in sharing my FMCSR records during and beyond my period of employment. A telephone facsimile (FAX) or a scanned or photographic copy of this authorization shall be as valid as the original. I acknowledge that Peek seeks to hire -- without discrimination -- only lawful workers. I hereby confirm my elegibility for legal employment within the U.S., and I understand that my identification and my elegibilty for legal employment within the U.S. will be verified by the U.S. Department of Homeland Security and the Social Security Administration. I understand that I am entitled to a statement of my rights under the Fair Credit Reporting Act. I understand that information regarding sex, race and date of birth is requested in compliance with federal and state laws and will not be used to discriminate against me. I certify the accuracy and completeness of all information I provide in this application and during my subsequent interview(s). I understand that providing false or misleading information may result in rejection of my application or a termination of my employment and associated benefits in the event that I am employed with Peek. Finally, I understand that I am required to abide by all of Peek's rules and regulations. Signature of applicant indication agreement to the above terms.*Date* Date Format: MM slash DD slash YYYY Previous Residency List all of the physical addresses at which you have resided during the past three(3) years prior to your current address.Address* Street Address Apt City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip How Long?Add Second Address Add Second Address Address Street Address Apt City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip How Long?Add Third Address Add Third Address Address Street Address Apt City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip How Long?Add Fourth Address Add Fourth Address Address Street Address Apt City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip How Long?Employment Record EMPLOYMENT WITH PEEK:Have you ever applied here before?*SelectYesNoIf yes, when?*Have you worked for this company before?*SelectYesNoIf yes, from* Date Format: MM slash DD slash YYYY to* Date Format: MM slash DD slash YYYY If you went by another name while employed with us, what was it?Do you know any current Peek Employees?*SelectYesNoIf yes, who?Are any of them relatives?*SelectYesNoIf yes, who?OTHER EMPLOYMENT:Are you currently employed?*SelectYesNoIf no, how long since your last employment?Do you have the legal right to work in the United States?SelectYesNoDo you have any felony convictions?SelectYesNoIf yes, please explain and include approximate date(s):We run background checks and honesty counts. Circumstances of convictions can be considered if listed here.Have you ever traveled as part of your job?SelectYesNoIf yes, for whom?Can you drive a manual or "stick" shift?SelectYesNoDo you understand what a "CDL" is and what is required to get one?SelectYesNoDo you have a CDL?SelectYesNoIMPORTANT: The U.S.D.O.T requires driver applicants to show all employment for the past 3 years and all commercial driving employment for the past 10 years. FMCSR 391.21(b)(10),(11). Please begin with your most recent employer.CURRENT OR LAST EMPLOYER:Have you been employed before?*SelectYesNoif yes:Name of EmployerAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip SupervisorPhoneReason for leaving:From: Date Format: MM slash DD slash YYYY To: Date Format: MM slash DD slash YYYY Position Held:Salary/WageWhile employed by this employer, were you subject to the FMCSRs?SelectYesNoWas this position designated as a safety-sensitive function subject to DOT-Regulated drug and alcohol testing?SelectYesNoAdd Previous Employer: Add Previous Employer PREVIOUS EMPLOYER:Name of EmployerAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip SupervisorPhoneReason for leaving:From: Date Format: MM slash DD slash YYYY To: Date Format: MM slash DD slash YYYY Position Held:Salary/WageWhile employed by this employer, were you subject to the FMCSRs?SelectYesNoWas this position designated as a safety-sensitive function subject to DOT-Regulated drug and alcohol testing?SelectYesNoAdd Previous Employer: Add Previous Employer PREVIOUS EMPLOYER:Name of EmployerAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip SupervisorPhoneReason for leaving:From: Date Format: MM slash DD slash YYYY To: Date Format: MM slash DD slash YYYY Position Held:Salary/WageWhile employed by this employer, were you subject to the FMCSRs?SelectYesNoWas this position designated as a safety-sensitive function subject to DOT-Regulated drug and alcohol testing?SelectYesNo The U.S.D.O.T. requires driver applicants to pass certain physical test before they are hired to drive for a motor carrier. FMCSR 391(E).Date of last Department of Transportation prescribed physical examination:Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of a foot, leg, hand, or arm?Date Date Format: MM slash DD slash YYYY Social Security Number*(The US DOT requires driver applicants to state their date of birth and provide their social security number.)Driver Licenses It is a DOT requirement that you List Each Unexpired Commercial Motor Vehicle Operator's License or Permit that has been issued to you and all Driver's Licences you have held during the previous three years. Unexpired CMV License/PermitState*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense Number*Expiration Date* Date Format: MM slash DD slash YYYY Type*How Long*Have you held more than one driver’s license within the last three years?SelectYesNoIf yes, List the State and Driver’s License Number StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense NumberExpiration Date Date Format: MM slash DD slash YYYY TypeHow LongAdd Second Driver's License Add Second Driver's License StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense NumberExpiration Date Date Format: MM slash DD slash YYYY TypeHow LongAdd Third Driver's License Add Third Driver's License StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense NumberExpiration Date Date Format: MM slash DD slash YYYY TypeHow LongA. Have you ever been denied a license, permit or privilege to operate a motor vehicle?*SelectYesNoB. Has any license, permit or privilege ever been suspended or revoked?*SelectYesNoC. Have you ever been disqualified for violations of Federal Motor Carrier Safety Regulations?*SelectYesNoA, B, and C above must be answered. If Yes to any of these questions, please explain facts/circumstances involved and include approximate dates:*Accident Reviews for the Past 3 YearsHave you had an accident in the past 3 years?*SelectYesNoIf yes, please complete the following questions and provide details of the accident on the text box below.Date Date Format: MM slash DD slash YYYY Nature of AccidentTicketedFatalitiesInjuriesAdd Accident: Add Accident: Date Date Format: MM slash DD slash YYYY Nature of AccidentTicketedFatalitiesInjuriesAdd Accident: Add Accident: Date Date Format: MM slash DD slash YYYY Nature of AccidentTicketedFatalitiesInjuriesExplain:Traffic Convictions and Forfeitures (Other than Parking Tickets)Have you had any traffic violations during the past 3 years which resulted in conviction or forfeiture? (Traffic Convictions And Forfeitures)SelectYesNoWe check driving records and honesty counts. Circumstances of convictions can be considered if listed here.If yes, please complete the following:DatesLocationChargePenalty Types of Vehicles DrivenHave you had experience driving equipment like the type listed below? If yes, please provide the correct information*SelectYesNoStraight TruckType of EquipmentFromToApproximateTractor / Semi-TrailerType of EquipmentFromToApproximateTwin TrailersType of EquipmentFromToApproximateOther EquipmentType of EquipmentFromToApproximateIn the past 5 years, I have driven the above equipment in the following states:Special Driver-Related Courses and/or Training UndertakenSafe Driving Awards Held and Awarding OrganizationEducationHighest Grade Completed*Select123456789101112CollegeSelectAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOtherPrefer Not to AnswerLast School Attended:NameAddressExperience and QualificationsIndicate training and experience in years in the following areas and if you have received formal training:Military ExperienceSteel WorkRoad ConstructionAutomotive RepairLandscapeEngine RepairFarmingForkliftHVACMachine OperationPlumbingCarpentryElectricalPaintingAdmin/ClericalWeldingOtherRoad/Pavement MarkingOther Construction (non-road)Concrete / Flat WorkEquipment OperationAdditional information you wish to provide:My signature certifies that this application was completed by me and that all entries on it are true and complete to the best of my knowledge.Applicant's SignatureDate Date Format: MM slash DD slash YYYY Application for Motor Vehicle ReportIf information is the same as above If information is the same as above Date of this application* Date Format: MM slash DD slash YYYY Name as they appear on driver's license*Date of Birth as it appears on driver's license*Driver's License State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDriver's License Number*Driver's License Expiration Date*APPLICANT STATEMENT: My signature authorizes release of information about my driving record to Fortson-Peek Co., and its subsidiaries.Applicant's Signature*Date* Date Format: MM slash DD slash YYYY Application for Background InvestigationI hereby authorize release of information about me to Fortson-Peek Co., and its subsidiary companies for the purpose of arriving at a decision relating to my employment. Agencies and services -- including but not limited to the following types of organizations -- are released from all liability for potential damages relating to provision of these records: government policing authorities; government regulatory/information services; private, third-party information reporting services. I understand that background investigation as it relates to my current application for employment is the sole purpose for these records.Full Legal Name* First Name Middle Name Last Name Sr., Jr, III, etc. Other names you are known bySexRaceDate of Birth* Date Format: MM slash DD slash YYYY SSN*Applicant's Signature*Date* Date Format: MM slash DD slash YYYY Regulated Drug & Alcohol Screening HistoryEmployers subject to Federal Motor Carrier Safety Regulations must ask prospective employees about their drug and alcohol screening history during the preceding 3-year period.1. During the preceding 3 years, have you worked for an Employer that was DOT Regulated?*SelectYesNo2. During the preceding 3 years, have you held a job that was designated as a "Safety Sensitive Function" in any DOT-regulated mode subject to alcohol and drug testing requirements as required by 49 CFR Part 40 of the FMCSA regulations?*SelectYesNo3. During the preceding 3 years, have you tested positive, or refused to participate in, a drug or alcohol test administered by an employer subject to Federal Motor Carrier Safety Regulations? [A refusal includes accepting employment termination rather than participating in a test, or substituting, or otherwise tampering with a sample.]*SelectYesNo4. Have you ever been denied a job with an employer subject to Federal Motor Carrier Safety Regulations because you tested positive, or failed to participate in a pre-employment drug or alcohol test?*SelectYesNoIMPORTANT: If you answered "YES" to question #1 and/or #2, you must provide a consent form, authorizing each former employer that met the conditions #1 and or #2, to release your Safety Performance History. You must provide that employers contact information (Address, Telephone #, Fax #). If you answered "YES" to questions #3 or #4, you must provide documentation of succesful completion of DOT's return-to-duty process before we can employ you.Applicant's Signature*Date* Date Format: MM slash DD slash YYYY Previous Employment with DOT-Regulated Employers (Previous 3 Years)Federal Motor Carrier Safety Regulations require prospective employers to request information from driver applicants concerning their experience driving commercially and/or working for DOT-regulated employers. Please complete the statement below, sign and date it.For the record, ISelectHaveHave Notworked for DOT-Regulated employer during the preceding 3 years. If checking "Have Not" above, I confirm that I have no DOT-Regulated driving history nor DOT-Regulated Drug and Alcohol history to investigate for the preceding 3-year period.Applicant's Signature*Date* Date Format: MM slash DD slash YYYY Health AffidavitName* First Date* Date Format: MM slash DD slash YYYY 1. Have you ever been injured in an accident? (Home, work, sports, school, auto, other)SelectYesNoIf yes, briefly describe injury suffered:2. Have you ever received a Worker's Compensation Payment?SelectYesNo3. Have you ever suffered a neck or back injury?SelectYesNo4. Do you now have or have you ever had any trouble with your back, other than a direct injury?SelectYesNo5. Have you ever had knee injury?SelectYesNo6. Have you ever suffered a heat related illness such as heat stroke or heat exhaustion?SelectYesNo7. Are you hard of hearing?SelectYesNo8. Date of last Tetanus shot? Date Format: MM slash DD slash YYYY 9. Do you now have or have you ever had a hernia?SelectYesNo10. Do you now have or have you ever treated for heart disease or high blood pressure?SelectYesNo11. Do you suffer from fainting spells?SelectYesNo12. Do you now have or have you ever been treated for epilepsy?SelectYesNo13. Do you now have or have you ever been treated for diabetes?SelectYesNo14. Do you have any allergies?SelectYesNo15. Do you now have normal or corrected to normal vision?SelectYesNo16. Do you agree to purchase and wear required clothing on the job?SelectYesNo17. Do you agree to abide by the safety rules in force and practiced by this company?SelectYesNoComments: ( Apart from questions 15. through 17., please explain any answer of "Yes").Applicant's Signature*Date* Date Format: MM slash DD slash YYYY State Job Applied For:*Please select a stateGeorgiaSouth CarolinaResume Upload