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PRINT AND MAIL THIS FORM
PERKINS SPECIALIZED TRANSPORTATION,
INC.
PERSONAL INFORMATION
| NAME:LAST:__________________ |
FIRST:__________________ |
M.I.:____________ |
| ADDRESS: |
STREET: |
APT#: |
| CITY: |
STATE: |
ZIP:: |
| HOME PHONE: |
OTHER#: |
PAGER: |
| SOC. SEC. #: |
DATE OF BIRTH: |
AGE: |
| DRIVER LIC #: |
STATE: |
TYPE: |
MOVING VIOLATION DURING THE PAST 3
YEARS
| DATE____ |
TYPE OF OFFENSE______________________________________________ |
| . |
. |
| . |
. |
| . |
. |
ACCIDENTS/INCIDENTS DURING THE PAST
3 YEARS
| DATE____ |
DESCRIPTION OF ACCIDENT____________________________________ |
| . |
. |
| . |
. |
HAVE YOU EVER FAILED OR REFUSED TO TAKE A DRUG OR
ALCOHOL TEST?
NO (__)
YES (__),
IF YES, EXPLAIN: _________________________________________
HAVE YOU EVER BEEN CONVICTED OF DUI, DWI OR A
SIMILAR OFFENSE?
NO (__)
YES (__),
IF YES, EXPLAIN: _________________________________________
HAVE YOU EVER BEEN CONVICTED OF A FELONY?
NO (__)
YES (__),
IF YES, EXPLAIN: _________________________________________
WORK HISTORY
START WITH CURRENT/ MOST RECENT
EMPLOYER AND LIST ALL JOBS WITHIN THE PAST 3 YEARS
| EMPLOYER
|
FROM |
POSITION HELD |
| ADDRESS |
. |
. |
| CITY__________________
STATE____ZIP_______ |
TO |
REASON FOR LEAVING |
| TELEPHONE NO. |
. |
. |
| EMPLOYER |
FROM |
POSITION HELD |
| ADDRESS |
. |
. |
| CITY__________________STATE_____ZIP_______ |
TO |
REASON FOR LEAVING |
| TELEPHONE NO. |
. |
. |
| EMPLOYER |
FROM |
POSITION HELD |
| ADDRESS |
. |
. |
| CITY___________________STATE____ZIP______. |
TO |
REASON FOR LEAVING |
| TELEPHONE NO. |
. |
. |
| EMPLOYER |
FROM |
POSITION HELD |
| ADDRESS |
. |
. |
| CITY__________________STATE_____ZIP______ |
TO |
REASON FOR LEAVING |
| TELEPHONE NO. |
. |
. |
| EMPLOYER |
FROM |
POSITION HELD |
| ADDRESS |
. |
. |
| CITY__________________STATE____ZIP_______ |
TO |
REASON FOR LEAVING |
| TELEPHONE NO. |
. |
. |
| EMPLOYER |
FROM |
POSITION HELD |
| ADDRESS |
. |
. |
| CITY__________________STATE____ZIP_______ |
TO |
REASON FOR LEAVING |
| TELEPHONE NO. |
. |
. |
| YOU MUST PROVIDE COMPLETE INFORMATION ON EACH PAST
EMPLOYER. |
DRIVER NOTIFICATION AND RELEASE
In conjunction with my application,
I understand that a consumer report which may contain public record
information is being requested from DAC Services, Tulsa, OK. This report may
include the following types of information: names and dates of previous
employers, reason for termination of employment, work experience, accidents,
etc. I further understand that such report may contain public record
information concerning my driving record from federal, state and other
agencies which maintain such records as well as information from DAC
concerning (1) previous driving record requests made by others from such
state agencies, (2) state provided driving record; (3) claims involving me
in the files of insurance companies.
In addition to the above, I
understand that Perkins Specialized Transportation is required to contact
all my employers during the past three (3) years for information concerning
my work history, including dates of employment, performance, accident
history, etc.
I AUTHORIZE, WITHOUT RESERVATION,
ANY PARTY OR AGENCY CONTACTED BY DAC OR PERKINS SPECIALIZED TRANSPORTATION,
TO FURNISH THE ABOVE-MENTIONED INFORMATION.
Print Name:
_______________________________ Social Security No.: ___________________
Signature:__________________________________________________ Date:
______________
Mail completed application to:
Recruiting Department
Perkins Specialized Transportation, Inc.
P. O. Box 78130
Indianapolis, IN 46278
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