Driver Application – Ancora Logistics

Name (Last Name First)

Social Security No.

City

State

Zip Code

Phone Number

Permanent Address

City

State

Zip Code

Secondary Phone Number

Email Address

Referred By

Position

Date Your Can Start

Are you employed now?

Yes No

If so, may we inquire of your present employer?

Yes No

Ever applied to this company before?

Yes No

Where

When

Ever worked for this company before?

Yes No

Where

When

Reason For Leaving

Name of last supervisor at this company

High School

Name & Location of School

Did you graduate?

Yes No

Subject Studies

College

Name & Location of School

Did you graduate?

Yes No

Subject Studies

Trade, Business, or Correspondence School

Name & Location of School

Did you graduate?

Yes No

Subject Studies

Subject of Special Study/Research Work

Special Training, Certifications, Licenses

Special Skills, Foreign Languages, etc.

Have you ever served in the U.S. Armed Forces?

Yes No

Branch of Service

Discharge Date

Rank

DO NOT ANSWER ANY OF THE QUESTIONS IN THIS BOX UNLESS THE EMPLOYER HAS CHECKED THE BOX PRECEDING A QUESTION, THEREBY INDICATING THAT THE INFORMATION IS REQUIRED FOR A BONA FIDE OCCUPATIONAL QUALIFICATION, OR DICTATED BY NATIONAL SECURITY LAWS, OR IS NEEDED FOR OTHER LEGALLY PERMISSIBLE REASONS. THE INFORMATION DISCLOSED WILL NOT BE USED TO DISCRIMINATE AGAINST THE APPLICANT DURING THE HIRING PROCESS FOR ANY REASONS RELATING TO RACE, COLOR, SEX, RELIGIOUS AFFILIATION, NATIONAL ORIGIN, GENDER, OR ANY DISABILITY..

Have you been convicted of a felony within the last 5 years?

Yes No

Describe

This question is being asked because the job for which you are applying is considered a "security-sensitive" job, requiring a very high level of trust, such as any position in which the employee handles currency, has access to a job-related computer terminal, has access to a master key, or works in an area or performs duties which are considered security-sensitive. Answering yes to this question will not result in automatic rejection of employment. The date of the offense, the seriousness and nature of the violation, rehabilitation, and position applied for will be considered. If your record was expunged, sealed or set aside, you may answer “no” to the above question.

I understand and agree that, in the event that I am offered a job, I may be required to take one or more: physical examination; drug test, as a condition of hiring or continued employment. I agree to consent to take such test(s) at such time as designated by the Company and to release the Company, its directors, officers, agents or employees from any claim arising in connection with the use of such test(s), other than claims related to privacy violations and/or discrimination under applicable federal and state laws. I understand that all potential employees are required to take a physical examination and/or drug test and that, in compliance with federal law, the records of such tests will be kept confidential and the information obtained will not be used to discriminate on the basis of disability, health problems, or medical conditions.

Yes No

Any information voluntarily disclosed in the following question will only be used by the employer to determine the extent of any employer-provided accommodations that may be necessary for the applicant under the American with Disabilities Act; the information disclosed will not be used to discriminate against the applicant during the hiring process for any reasons relating to disabilities, health problems, or medical conditions.

Are you able to perform each of the following job functions with or without an accommodation?

JOB FUNCTION#1

If you can perform the function with an accommodation, explain how you would perform the tasks, and with what accommodation?

JOB FUNCTION#2

If you can perform the function with an accommodation, explain how you would perform the tasks, and with what accommodation?

JOB FUNCTION#3

If you can perform the function with an accommodation, explain how you would perform the tasks, and with what accommodation?

What foreign languages do you speak/write/read fluently?

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment.* This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

Date

Signature

LIST BELOW LAST THREE EMPLOYERS, STARTING WITH MOST RECENT

Name of Present or Last Employer

Address

City

State

Zip

Starting Date

Leaving Date

Job Tiitle

MAY WE CONTACT YOUR SUPERVISOR?

Yes No

Name of Supervisor

Title

Phone

Description Of Work

Reason For Leaving

Name of Previous Employer

Address

City

State

Zip

Starting Date

Leaving Date

Job Tiitle

MAY WE CONTACT YOUR SUPERVISOR?

Yes No

Name of Supervisor

Title

Phone

Description Of Work

Reason For Leaving

Name of Previous Employer

Address

City

State

Zip

Starting Date

Leaving Date

Job Tiitle

MAY WE CONTACT YOUR SUPERVISOR?

Yes No

Name of Supervisor

Title

Phone

Description Of Work

Reason For Leaving

Name

Address

Business

Phone

Name

Address

Business

Phone

Name

Address

Business

Phone

Application For Employement

High School

College

Trade, Business, or Correspondence School

JOB FUNCTION#1

JOB FUNCTION#2

JOB FUNCTION#3

LIST BELOW LAST THREE EMPLOYERS, STARTING WITH MOST RECENT

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Working Hours

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