Cecil D. Gassiott, L.L.C. ~ Contractors

Federal Government / State Government
Heavy / Civil
Roadway / Bridges / Pile Driving
Utilities / Infrastructure
Municipal and Public Works
Structural Steel and Complex Concrete
Electrical
Gas
Wood Processing / Chemical Industries
Steel / Metal Buildings
Levees / Embankments
Marine and Bargework

APPLICATION FOR EMPLOYMENT

Company:

Street Address:

Name:


(First)	(Middle)	(Last)

Address:


(Street)	(City)	(State & Zip Code)

How Long?

Date Of Birth:

Social Security No.:

Hire Date:

Telephone Number:

Email Address:

Privious Three Years Residency

Street	City	State/Zip Code	Years



(Attach Sheet If More Space Is Needed)

License Information

Section 383.21 FMCSR states "No person who operates a commercial vehicle shall at any time have more than one driver's license^*.I certify that I do not have more than one motor vehicle license,the information for which is listed below.

State	License No.	Type	Expiration Date

Driving Experience

Class Of Equipment	Type Of Equipment	Dates	Approx. No. Of Mils (Total)
Straight Truck
Tractor And Semi-Tractor
Tractor - Two Wheelors
Other

Accident Record For Past 3 Years Or More

Dates	Nature Of Accident (Head-On,Rear-End,Upset,Etc.)	Number Fatalities	Number Injuries	Chemical Spills
				Yes No
				Yes No
				Yes No

Traffic Convictions And Forfeitures For The Past 3 Years (Other Than Parking Volations)

Date Convicted(month/year)	Violation	State Of Violation Location	Penalty(forfeited bond,collateral and/or points)

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes No

If yes,explain

B. Has any license, permit or privilege ever been suspended or revoked?

Yes No

If yes,explain

Employment Record

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three yeas. You must give the same imformation for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).

Must list the complete mailing address: street number and name, city, state and zip code.

Last Employer: Name

Address:

Phone:

Position Held:

From: To:

Salary:

Reason For Leaving:

Any Gaps In Employment And/Or Unemployment Must Be Explained. Include Dates(Month/Year) And Reason.

Were you subject to the Federal Motor Carrier Safty Regulations (FMCSRs) while employed by previous employer?:

Yes No

Was the previous job position designated as a saftey sensitive function in any DOT regulated mode, subject to alcohol and controled substances testing requirements as required by 49 CFR Part 40?:

Yes No

Second Last Employer: Name

Address:

Phone:

Position Held:

From: To:

Salary:

Reason For Leaving:

Any Gaps In Employment And/Or Unemployment Must Be Explained. Include Dates(Month/Year) And Reason.

Were you subject to the Federal Motor Carrier Safty Regulations (FMCSRs) while employed by previous employer?:

Yes No

Was the previous job position designated as a saftey sensitive function in any DOT regulated mode, subject to alcohol and controled substances testing requirements as required by 49 CFR Part 40?:

Yes No

Third Last Employer: Name

Address:

Phone:

Position Held:

From: To:

Salary:

Reason For Leaving:

Any Gaps In Employment And/Or Unemployment Must Be Explained. Include Dates(Month/Year) And Reason.

Were you subject to the Federal Motor Carrier Safty Regulations (FMCSRs) while employed by previous employer?:

Yes No

Was the previous job position designated as a saftey sensitive function in any DOT regulated mode, subject to alcohol and controled substances testing requirements as required by 49 CFR Part 40?

Yes No

To Be Read And Signed By Applicant

I authorize you to make sure investigations and inquires to my personal, employment, financial or medical and other related metters 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, school, health care providers and other persons from all liability in responding to inquries 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 employers(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 right to:

Review information provided by current/previous employers:
Have errors in the information corrected by previious employers and for those previous employers to re-send the corrected information to the prospective employer: and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I can not agree on the accuracy of the information."

Date: Applicant Signture:

This certifies that I completed this application, that all entries on it and information in it are true and complete to the best of my knowledge.

Date: Applicant Signture:

Note: A motor carrier may require an applicant to provide information in addition to the information required by the federal Motor Carrier Safety Regulations.

Security Code:

Please allow up to 60 seconds for application to submit.

APPLICATION FOR EMPLOYMENT

License

Links

Contact information