form testing

Employment Application

Name*
First Last
Middle
Address*
Street Address Apt City State Zip
Phone*
Mobile Phone
Other Phone
Provide at least one phone number where you can be reached.
Email*
Who Referred You?*
Position Applying For
Location Applying For*
Please 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*
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 State Zip
How Long?
Add Second Address
- Add Second Address
Address
Street Address Apt City State Zip
How Long?
Add Third Address
- Add Third Address
Address
Street Address Apt City State Zip
How Long?
Add Fourth Address
- Add Fourth Address
Address
Street Address Apt City State Zip
How Long?
Employment Record
EMPLOYMENT WITH PEEK:
Have you ever applied here before?*
If yes, when?*
Have you worked for this company before?*
If yes, from*
MM slash DD slash YYYY
to*
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?*
If yes, who?
Are any of them relatives?*
If yes, who?
OTHER EMPLOYMENT:
Are you currently employed?*
If no, how long since your last employment?
Do you have the legal right to work in the United States?
Do you have any felony convictions?
If 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?
If yes, for whom?
Can you drive a manual or "stick" shift?
Do you understand what a "CDL" is and what is required to get one?
Do you have a CDL?
IMPORTANT: 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?*
if yes:
Name of Employer
Address
Street Address City State Zip
Supervisor
Phone
Reason for leaving:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Position Held:
Salary/Wage
While employed by this employer, were you subject to the FMCSRs?
Was this position designated as a safety-sensitive function subject to DOT-Regulated drug and alcohol testing?
Add Previous Employer:
- Add Previous Employer
PREVIOUS EMPLOYER:
Name of Employer
Address
Street Address City State Zip
Supervisor
Phone
Reason for leaving:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Position Held:
Salary/Wage
While employed by this employer, were you subject to the FMCSRs?
Was this position designated as a safety-sensitive function subject to DOT-Regulated drug and alcohol testing?
Add Previous Employer:
- Add Previous Employer
PREVIOUS EMPLOYER:
Name of Employer
Address
Street Address City State Zip
Supervisor
Phone
Reason for leaving:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Position Held:
Salary/Wage
While employed by this employer, were you subject to the FMCSRs?
Was this position designated as a safety-sensitive function subject to DOT-Regulated drug and alcohol testing?
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
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/Permit
State*
License Number*
Expiration Date*
MM slash DD slash YYYY
Type*
How Long*
Have you held more than one driver’s license within the last three years?
If yes, List the State and Driver’s License Number
State
License Number
Expiration Date
MM slash DD slash YYYY
Type
How Long
Add Second Driver's License
- Add Second Driver's License
State
License Number
Expiration Date
MM slash DD slash YYYY
Type
How Long
Add Third Driver's License
- Add Third Driver's License
State
License Number
Expiration Date
MM slash DD slash YYYY
Type
How Long
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
B. Has any license, permit or privilege ever been suspended or revoked?*
C. Have you ever been disqualified for violations of Federal Motor Carrier Safety Regulations?*
A, 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 Years
Have you had an accident in the past 3 years?*
If yes, please complete the following questions and provide details of the accident on the text box below.
Date
MM slash DD slash YYYY
Nature of Accident
Ticketed
Fatalities
Injuries
Add Accident:
- Add Accident:
Date
MM slash DD slash YYYY
Nature of Accident
Ticketed
Fatalities
Injuries
Add Accident:
- Add Accident:
Date
MM slash DD slash YYYY
Nature of Accident
Ticketed
Fatalities
Injuries
Explain:
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)
We check driving records and honesty counts. Circumstances of convictions can be considered if listed here.
If yes, please complete the following:
Dates Location Charge Penalty
Types of Vehicles Driven
Have you had experience driving equipment like the type listed below? If yes, please provide the correct information*
Straight Truck
Type of Equipment From To Approximate
Tractor / Semi-Trailer
Type of Equipment From To Approximate
Twin Trailers
Type of Equipment From To Approximate
Other Equipment
Type of Equipment From To Approximate
In the past 5 years, I have driven the above equipment in the following states:
Special Driver-Related Courses and/or Training Undertaken
Safe Driving Awards Held and Awarding Organization
Education
Highest Grade Completed*
College
Last School Attended:
Name
Address
Experience and Qualifications
Indicate training and experience in years in the following areas and if you have received formal training:
Military Experience
Steel Work
Road Construction
Automotive Repair
Landscape
Engine Repair
Farming
Forklift
HVAC
Machine Operation
Plumbing
Carpentry
Electrical
Painting
Admin/Clerical
Welding
Other
Road/Pavement Marking
Other Construction (non-road)
Concrete / Flat Work
Equipment Operation
Additional 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 Signature
Date
MM slash DD slash YYYY
Application for Motor Vehicle Report
Hidden
If information is the same as above
- If information is the same as above
Date of this application*
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*
Driver'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*
MM slash DD slash YYYY
Application for Background Investigation
I 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 by
Sex
Race
Date of Birth*
MM slash DD slash YYYY
SSN*
Applicant's Signature*
Date*
MM slash DD slash YYYY
Regulated Drug & Alcohol Screening History
Employers 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?*
2. 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?*
3. 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.]*
4. 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?*
IMPORTANT: 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*
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, I
worked 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*
MM slash DD slash YYYY
Health Affidavit
Name*
First
Date*
MM slash DD slash YYYY
1. Have you ever been injured in an accident? (Home, work, sports, school, auto, other)
If yes, briefly describe injury suffered:
2. Have you ever received a Worker's Compensation Payment?
3. Have you ever suffered a neck or back injury?
4. Do you now have or have you ever had any trouble with your back, other than a direct injury?
5. Have you ever had knee injury?
6. Have you ever suffered a heat related illness such as heat stroke or heat exhaustion?
7. Are you hard of hearing?
8. Date of last Tetanus shot?
MM slash DD slash YYYY
9. Do you now have or have you ever had a hernia?
10. Do you now have or have you ever treated for heart disease or high blood pressure?
11. Do you suffer from fainting spells?
12. Do you now have or have you ever been treated for epilepsy?
13. Do you now have or have you ever been treated for diabetes?
14. Do you have any allergies?
15. Do you now have normal or corrected to normal vision?
16. Do you agree to purchase and wear required clothing on the job?
17. Do you agree to abide by the safety rules in force and practiced by this company?
Comments: ( Apart from questions 15. through 17., please explain any answer of "Yes").
Applicant's Signature*
Date*
MM slash DD slash YYYY
State Job Applied For:*
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Employment Application

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