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Driver Application Form

I Supply Company
&
Parisi Transportation
1255 Spangler Road
P.O. Box 1739
Fairborn, OH 45324
www.isupplyco.com

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age marital status, or non-job related disability.

Please fill out the form below and click the submit button:

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Please Answer All Questions.
All fields with an asterisk (*) are required

CONTACT INFORMATION:
First Name:*
Middle Name:
Last Name:*
Social Security Number:*

List your addresses of residency for the past 3 years.

Current Address:
Street Address:*
Apartment/Suite:
City:*
State:*
Zip:*
Length of Residence:* 

Phone #:*
(Include Area Code)
Alternate Phone #:*
(Include Area Code)
Cell Phone #:
(Include Area Code)
Best Time to Call:
E-mail Address:
Previous Address 1:
Street Address:
Apartment/Suite:
City:
State:
Zip:
Length of Residence:
Previous Address 2:
Street Address:
Apartment/Suite:
City:
State:
Zip:
Length of Residence:
Previous Address 3:
Street Address:
Apartment/Suite:
City:
State:
Zip:
Length of Residence:
County of Residence for Past 3 Years:*
Do you have the legal right to work in the United States:* Yes No
Date of Birth:* Month: Day: Year:
Can you provide proof of age?:* Yes No
Have you ever applied at I Supply Company before?:* Yes No
If Yes, when?
Have you ever worked at I Supply Company before?:* Yes No
Position:
Dates: From To
Who referred you (Be specific)?:*

DRIVER EXPERIENCE AND QUALIFICATIONS:
If no driving experience within the last 3 years, check here

Class of Equipment Type of Equipment
(Reefer, Straight, etc.)		 Dates:
From:     To:		 Approx. # of Miles
Straight Truck
Tractor and Semi-Trailer
Tractor-Two Trailers
Motorcoach - Schoolbus
Other

ACCIDENT HISTORY:
Report any accidents you have had in the last 3 years.

Number of Accidents:*
Please list Date, Nature of Accidents(Head-One, Rear End, Side etc.), Fatalities & Injuries for EACH accident. :

TRAFFIC CONVICTIONS AND FORFEITURES (5 years):
Report all traffic convictions from the past 5 years.
Number of traffic convictions and forfeitures in the past 5 years:*
Please list Location, Date, Charge, and Penalty :

LICENSE INFORMATION

Section 383.21 FMCSR states "No person who operates a commercial motor 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, as listed below:
State:*
Class:* Class A Class B Class C
How long have you had your CDL:* A B
Driver’s License Number:*
Expiration Date:* Month: Day: Year:
Endorsements:* Hazmat Material Double/Triple
Tanker      None
Have you ever been denied a license to operate a motor vehicle?:* Yes No
If Yes, explain:
Has your license ever been suspended or revoked?:* Yes No
If Yes, explain:

EDUCATION:

Highest Education Received:*
Last School Attended:*

Name:
City:   

ADDITIONAL TRAINING AND EXPERIENCE:
List any trucking, transportation or other experience that may help in your work for this company:
List any other courses, training, special equipment or safe driving awards you have that you feel may help in our consideration of your application for employment:
Have you been convicted of any felonies in the past 7 years? Yes No
If Yes, explain:
EMPLOYMENT HISTORY:
All driver applicants to I Supply Company must provide all employers for the past 10 years.
You are required to list complete mailing address, street number, city state and zip code.
(NOTE: List employers in reverse order starting with the most recent first)
Any gaps in employment and unemployment must be explained, please include date and reason:
Current or Last Employer: *
 From: * To:*
Street Address/City/State/Zip: *
 Position Held: *
Contact Person:
Salary/Wage: *
Phone Number: *
 Reason for Leaving: *
Estimated Days Missed: *
Was your job designated as safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Yes No 		Was your job subject to Federal Motor Carrier Safety Regulations while employed?
Yes No
Second Last Employer:
From: To:
Street Address/City/State/Zip:
Position Held:
Contact Person:
Salary/Wage:
Phone Number
Reason for Leaving:
Estimated Days Missed
Was your job designated as safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Yes No 		Was your job subject to Federal Motor Carrier Safety Regulations while employed?
Yes No
Third Last Employer:
From: To:
Street Address/City/State/Zip:
Position Held:
Contact Person:
Salary/Wage:
Phone Number
Reason for Leaving:
Estimated Days Missed
Was your job designated as safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Yes No 		Was your job subject to Federal Motor Carrier Safety Regulations while employed?
Yes No
Fourth Last Employer:
From: To:
Street Address/City/State/Zip:
Position Held:
Contact Person:
Salary/Wage:
Phone Number
Reason for Leaving:
Estimated Days Missed
Was your job designated as safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Yes No 		Was your job subject to Federal Motor Carrier Safety Regulations while employed?
Yes No
Fifth Last Employer:
From: To:
Street Address/City/State/Zip:
Position Held:
Contact Person:
Salary/Wage:
Phone Number
Reason for Leaving:
Estimated Days Missed
Was your job designated as safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Yes No 		Was your job subject to Federal Motor Carrier Safety Regulations while employed?
Yes No
Sixth Last Employer:
From: To:
Street Address/City/State/Zip:
Position Held:
Contact Person:
Salary/Wage:
Phone Number
Reason for Leaving:
Estimated Days Missed
Was your job designated as safety sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Yes No 		Was your job subject to Federal Motor Carrier Safety Regulations while employed?
Yes No

TO BE READ AND SIGNED BY APPLICANT

This certifies that all entries on this application and information in it are true and complete to the best of my knowledge. I authorize any inquires of my personal, employment, financial or medical history, driving records and other rated matters as may be necessary in arriving at an employment decision. 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.
If you accept these terms, please provide your initials 
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