JRose Trucking, LLC

* Position(s) Applying for:

* Last Name:
* First Name:
* Middle Name:
* Date of Birth:	(mm/dd/yyyy)
* Social Security No.:	(numbers only)
* Phone:	(numbers only)
Email:

* Address:
* City:
* State:
* Zip:
* Length of residency:

Address:
City:
State:
Zip:
Length of residency:

Address:
City:
State:
Zip:
Length of residency:

* Can you legally work in the United States?	Yes No
* Can you provide proof of age?	Yes No

* Have you worked for this company before?	Yes No
Location:
From Date:	To Date: (mm/dd/yyyy)
Pay Rate:
Position:
Reason for leaving:
* Are you currently employed?	Yes No
Date of last employment:	(mm/dd/yyyy)
* Have you ever been bonded?	Yes No
Name of bonding company:
* Can you perform all duties Required by this position with little or no difficulty?	Yes No
Explain if you wish:

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

Company Name:
Address:
City:
State:
Zip:
Contact Person:
Phone Number:	(numbers only)
Employment start date:	End date: (mm/yyyy)
Position Held:
Salary / Wage:
Reason for leaving:
Were you subject to the FMCSRs while employed?	Yes No
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?	Yes No

Company Name:
Address:
City:
State:
Zip:
Contact Person:
Phone Number:	(numbers only)
Employment start date:	End date: (mm/yyyy)
Position Held:
Salary / Wage:
Reason for leaving:
Were you subject to the FMCSRs while employed?	Yes No
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?	Yes No

Company Name:
Address:
City:
State:
Zip:
Contact Person:
Phone Number:	(numbers only)
Employment start date:	End date: (mm/yyyy)
Position Held:
Salary / Wage:
Reason for leaving:
Were you subject to the FMCSRs while employed?	Yes No
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?	Yes No

Please list your accident records for the past 3 years.

Date of Accident:	(mm/dd/yyyy)
Nature of Accident:
Number of Fatalities (if any):
Number of Injured Persons (if any):
Type of Hazardous Spill (if any):

Date of Accident:	(mm/dd/yyyy)
Nature of Accident:
Number of Fatalities (if any):
Number of Injured Persons (if any):
Type of Hazardous Spill (if any):

Date of Accident:	(mm/dd/yyyy)
Nature of Accident:
Number of Fatalities (if any):
Number of Injured Persons (if any):
Type of Hazardous Spill (if any):

Please list traffic convictions and forefeitures for the past 3 years.

Location:
Date:	(mm/dd/yyyy)
Charge:
Penalty:

Location:
Date:	(mm/dd/yyyy)
Charge:
Penalty:

Location:
Date:	(mm/dd/yyyy)
Charge:
Penalty:

Please list drivers licenses or permits held in the past 3 years.

* State:
* License Number:
* Class:
List all Endorsements:	(P, T, X, H, S, N)
* Expiration Date:	(mm/dd/yyy)

State:
License Number:
Class:
List all Endorsements:	(P, T, X, H, S, N)
Expiration Date:	(mm/dd/yyy)

State:
License Number:
Class:
List all Endorsements:	(P, T, X, H, S, N)
Expiration Date:	(mm/dd/yyy)

* Have you ever been denied a license, permit or Privilege to operate a motor vehicle?	Yes No
Give Details:
* Has any license or privilege ever been suspended or revoked?	Yes No
Give Details:

* Straight Truck:	Yes No
* Tractor and Semi-Trailer:	Yes No
* Tractor and Two Trailers:	Yes No
* Tractor and Three Trailers:	Yes No
* Motorcoach / School Bus (8 passenger):	Yes No
* Motorcoach / School Bus (15 passenger):	Yes No
* List states operated in (last five years):	(AL,AZ, exc...)
List special courses or training that will help you as a driver:
List any safe driving awards and who from:
List any other experience that may help in your work for this company:

* Highest Grade Completed:
* Name of last school attended:
* City:
*State:

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: Review information provided by previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employers; and 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.

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 knowledge.

* I accept