Tri-Hi Job Application Form   Tri-Hi Job Application Form To apply for a job at Tri-Hi, please fill out this form completely and accurately. Remember that this application is not completed until you click on the *Submit Job Application* button at the bottom of the page. This form will be emailed to Doug Lokemoen for immediate processing. General Information Check One: Contractor Driver Contractor's Driver Name: Phone Number: Emergency Phone Number: *Age: Date of Birth: Social Security Number:   DOT Physical Exam Expiration Date:   *The age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less 70 years of age. Have you worked for this company before? Yes No If yes, give dates: From To Reason for leaving? Current & Three Years Previous Addresses Address From To Education History Grade School: None 1 2 3 4 5 6 7 8 9 10 11 12 Collage: None 1 2 3 4 Post-Graduate: None 1 2 3 4 Employment History Give a Complete Record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past ten years. Present or Last Employer From:   Position Held: To:   Reason for Leaving: Name: Address: Phone: Where you subject to the FMCSRs* while employed here?: 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 Present or Last Employer From:   Position Held: To:   Reason for Leaving: Name: Address: Phone: Where you subject to the FMCSRs* while employed here?: 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 Present or Last Employer From:   Position Held: To:   Reason for Leaving: Name: Address: Phone: Where you subject to the FMCSRs* while employed here?: 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 Present or Last Employer From:   Position Held: To:   Reason for Leaving: Name: Address: Phone: Where you subject to the FMCSRs* while employed here?: 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 Present or Last Employer From:   Position Held: To:   Reason for Leaving: Name: Address: Phone: Where you subject to the FMCSRs* while employed here?: 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 *The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle:(1) has a GVWR or weighs 10,001 pounds or more, (2) is desingned or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding. Driving Experience Class of Equipment From To Approximate Number of Miles (Total) Straight Truck Tractor and Semi-Trailer Tractor-two Trailers Tractor-three Trailers (triples) Other List states operated in, for the last five years: List special courses/training completed (PTD/DDC, Haz Mat, etc.): List any Safe Driving Awards you hold and from whom: Accident Record for past three years NOTE: Skip this section if you are *not* applying for a driving position Date of Nature of Accident Location of # of # of People Accident (Head-on, rear end, etc) Accident Fatalities Injured None 1 2 3 4 5 6 7 8 9 10 over 10 None 1 2 3 4 5 6 7 8 9 10 over 10 None 1 2 3 4 5 6 7 8 9 10 over 10 None 1 2 3 4 5 6 7 8 9 10 over 10 None 1 2 3 4 5 6 7 8 9 10 over 10 None 1 2 3 4 5 6 7 8 9 10 over 10 Traffic Convictions and Forfeitures for the last three years Do *not* include parking violations NOTE: Skip this section if you are *not* applying for a driving position Date Location Charge Penalty Drivers License List each drivers license held in the past three years NOTE: Skip this section if you are *not* applying for a driving position State License # Type Endorsements Expire Date AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Regular CDL License CDL Learners AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Regular CDL License CDL Learners AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Regular CDL License CDL Learners Personal References Name Address Phone Other Questions Have you ever been denied a license, permit, or privilege to operate a motor vehicle?   Yes No Has any license, permit, or privilege ever been suspended or revoked?   Yes No Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)   Yes No Have you ever been convicted of a felony?   Yes No If you answered *yes* to any of the above four questions, please explain: Thank you for filling out the online application. Now please read the disclaimer then click on the *Submit Job Application* button to complete the application. Disclaimer It is agreed and understood that any misrepresentation given on this application for qualification shall be considered an act of dishonesty. I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. Tri-Hi Transportation Inc. Will investigate your safety performance history. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. It is agreed and understood that this is an application for qualification in no way obligates the motor carrier to employ me. It is agreed and understood that if qualified to operate motor carrier equipment, I may be on a probationary period, during which I may be disqualified without recourse. By clicking on the submit button, I certify 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.    >>TOP

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