Required fields are marked * General InformationName* First Middle Initial Last Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security #* Phone #*Email Wage Desired Position Desired Date Available MM slash DD slash YYYY What hours and days are you available to work?EducationHigh School High School City, State High School Degrees or Certificates College or Business School College or Business School City, State College or Business School Degrees or Certificates Vocational or other School Vocational or other School City, State Vocational or other School Degrees or Certificates Driver InformationIf applying for driving job complete the following:Are you 18 years of age or older?Please Choose...YesNoAddress for the past 3 years:Address 1 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Long? Address 2 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Long? List All Current Drivers LicencesStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense No. Type Hazmat & Tanker Endorsements Expiration Date StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense No. Type Hazmat & Tanker Endorsements Expiration Date A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No Please Provide DetailsB. Has any license, permit, or privilege ever been suspended or revoked? Yes No Please Provide DetailsDriving ExperienceStraight Truck Class Equipment Type (Van, Tank, Flat, Etc) Date Driven From Date Driven To Approx. No. of Miles Tractor/Semi-Trailer Class Equipment Type (Van, Tank, Flat, Etc) Date Driven From Date Driven To Approx. No. of Miles Driving ExperienceTractor-Two Trailers Class Equipment Type (Van, Tank, Flat, Etc) Date Driven From Date Driven To Approx. No. of Miles Other Class Equipment Type (Van, Tank, Flat, Etc) Date Driven From Date Driven To Approx. No. of Miles Accident RecordLast Accident Date Nature of Accident (Head-On, Rear End, Upset, Etc.) Fatalities Injuries Next Previous Date Nature of Accident (Head-On, Rear End, Upset, Etc.) Fatalities Injuries Next Previous Date Nature of Accident (Head-On, Rear End, Upset, Etc.) Fatalities Injuries Traffic Convictions & Forfeitures (other than parking violations)Location Date Charge Penalty Location Date Charge Penalty Location Date Charge Penalty Previous EmploymentCompany 1 - Name Company 1 - Address Company 1 - Phone #Company 1 - Positions/Duties Company 1 - Reason for Leaving Company 1 - Pay Rate Company 1 - Hire Date Company 1 - Leaving Date Company 2 - Name Company 2 - Address Company 2 - Phone #Company 2 - Positions/Duties Company 2 - Reason for Leaving Company 2 - Pay Rate Company 2 - Hire Date Company 2 - Leaving Date Company 3 - Name Company 3 - Address Company 3 - Phone #Company 3 - Positions/Duties Company 3 - Reason for Leaving Company 3 - Pay Rate Company 3 - Hire Date Company 3 - Leaving Date Company 4 - Name Company 4 - Address Company 4 - Phone #Company 4 - Positions/Duties Company 4 - Reason for Leaving Company 4 - Pay Rate Company 4 - Hire Date Company 4 - Leaving Date Additional InformationReferred ByMake a selection...NewspaperAgencyWalk-inIndividualIndividual's Name Can you show proof that you have a legal right to work permanently in the U.S.?Make a selection...YesNoHave you ever been convicted of a felony?Make a selection...YesNoPlease explain and list date and city & state of conviction:References (Business Only)Reference 1 - Name First Last Reference 1 - Company Reference 1 - Address Reference 1 - PhoneReference 2 - Name First Last Reference 2 - Company Reference 2 - Address Reference 2 - PhoneReference 3 - Name First Last Reference 3 - Company Reference 3 - Address Reference 3 - PhoneReference 4 - Name First Last Reference 4 - Company Reference 4 - Address Reference 4 - PhoneTO BE READ AND SIGNED BY APPLICANT This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowlege. I do hereby authorize the investigaion of any and all statements contained in said application. I understand that any false statements or misrepresentations of facts in this application will constitute sufficient cause for my dismissal. I am willing to take a physical examination to include drug and alcohol testing when requested. If employed, I understatnd that employent by Benz Oil Co. Inc. is solely on an at will basis and that this cannot be changed except in writing, signed by the President of the Company.Date* MM slash DD slash YYYY Signature* Completing this field acts as your signature.
