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The candidate has indicated the following:
|
First
Name
ENCRYPTED |
Last
Name
ENCRYPTED |
|
E-Mail
Address
ENCRYPTED |
SS
Number
ENCRYPTED |
DOB
ENCRYPTED |
Address
ENCRYPTED
ENCRYPTED |
|
|
City
Ft. Dodge |
State
IA |
Zip
50501 |
Main
Telephone
ENCRYPTED |
Cell
Phone
ENCRYPTED |
Pager
ENCRYPTED |
Best Way To Be
Reached
cell phone |
|
Best Time To Be
Reached
Evenings |
| CDL |
Number of years for CDL |
|
| Y |
<1 year |
|
| Profile Type |
Recent Equipment
Experience |
|
| Recent Grad |
Van, Flatbed |
|
| |
|
|
Driver Lic. #
ENCRYPTED |
Class
A |
State Issued
IA |
| |
|
|
License Expiration Date
05/06/2015 |
Years of Recent Driving Experience
<1 year |
Endorsements
Acquired
|
| Number of
Accidents: |
Number of Moving
Violations: |
| 0 in the last 3 years |
0 in the last 5 years |
| Willing to
Drive Team |
N |
| License Revoked
or Suspended |
N |
| Cited for DUI
or DWI |
N |
| If Yes, How Many Years Ago? |
|
| Convicted of a
Misdemeanor |
Y |
Convicted of a
Felony
|
Y |
Tractor
Manufacturer
|
Year/Model
|
Type
|
Engine
Size
|
Max
RPM
|
Electronically
Controlled?
|
Ratio
|
Tractor
Weight
|
Wheelbase
|
5th Wheel
Height
|
Trailer
Ownership
|
Trailer
Type
|
|
School's
Name
Iowa Central Community College |
School's
Location
Ft.Dodge,Ia |
Grad
Date
06/11/2010 |
Company
ENCRYPTED |
From
11/11/08 |
To
ENCRYPTED |
Address1
ENCRYPTED |
Address2
ENCRYPTED |
|
City
ENCRYPTED |
State
|
|
Telephone
ENCRYPTED |
Supervisor
ENCRYPTED |
Type
of Trailer(s)
|
Reason for
Leaving
|
|
|
Company
|
From
|
To
|
Address1
|
Address2
|
|
City
|
State
|
|
Telephone
|
Supervisor
|
Type
of Trailer(s)
|
Reason for
Leaving
|
|
|
Company
|
From
|
To
|
Address1
|
Address2
|
|
City
|
State
|
|
Telephone
|
Supervisor
|
Type
of Trailer(s)
|
Reason for
Leaving
|
|
|
|
Can former employers be contacted (Y or
N): |
| Date available:
ENCRYPTED |
On submitting this form,
ENCRYPTED ENCRYPTED certified that it was
personally completed and that all presented information is true and
correct. This driver authorizes any company that receives this
application to cause to be conducted, at any time, an investigation
of presented background for employment purposes, which may include,
but is not limited to, any information relating to character,
general reputation, personal characteristics, mode of living,
criminal history, past work experience, educational background,
alcohol or drug test results, or failure to submit to an alcohol or
drug test, or any other information about which may reflect upon
potential for employment gathered from any individual, organization,
entity, agency, or other source which may have knowledge concerning
any such items of information. All HRInterchange users certified
that they completed this form of their own free will and hold
HRInterchange harmless of all liability for providing it.
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