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Name
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First
Last
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ZIP Code
Position Applying For
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Desired Salary
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Date Available to Start
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MM slash DD slash YYYY
Date of Birth
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MM slash DD slash YYYY
Are you 16 years of age or older?
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Yes
No
Are you a United States citizen?
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Yes
No
Are you authorized to work in the United States?
Yes
No
Have you ever worked for this company?
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Yes
No
If yes, when did you work here?
Yes
No
Have you ever been convicted of a felony?
(Required)
Yes
No
If yes, please explain:
Education
High School
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Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
HS Attended From
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MM slash DD slash YYYY
HS Attended To
(Required)
MM slash DD slash YYYY
Did you graduate High School?
(Required)
Yes
No
College
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
College Attended From
MM slash DD slash YYYY
College Attended To
MM slash DD slash YYYY
Did you graduate college?
Yes
No
Other Education
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Other: Attended From
MM slash DD slash YYYY
Other: Attended To
MM slash DD slash YYYY
Did you graduate?
Yes
No
Employment History
Company 1
(Required)
Company Phone 1
(Required)
Company Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Job Title
(Required)
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Duties & Responsibilities
(Required)
Reason for Leaving
(Required)
May we contact your previous supervisor for a reference?
(Required)
Yes
No
Company Name 2
Company Phone 2
Company Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Job Title
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Duties & Responsibilities
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes
No
Company Name 3
Company Phone 3
Company Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Job Title
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Duties & Responsibilities
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes
No
Military Service
Branch
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Rank at Discharge
Type of Discharge
If other than honorable, please explain:
CDL
Class
Additional Endorsements
References
You must include 3 references.
Reference 1: Name
(Required)
First
Last
Relationship
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Phone
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Email
(Required)
Reference 2: Name
(Required)
First
Last
Relationship
(Required)
Phone
(Required)
Email
(Required)
Reference 3: Name
(Required)
First
Last
Relationship
(Required)
Phone
(Required)
Email
(Required)
Notice to Applicants
I understand that employment with Patriot Motors & Equipment is at-will, meaning that I or Patriot Motors & Equipment may terminate my employment at any time, or for any reason consistent with applicable state or federal law. I authorize the employer to make such inquiries and investigations of my personal, employment, driving, 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 authorize Patriot Motors & Equipment to verify all data given on this application and during interviews. I hereby release Patriot Motors & Equipment, and its representatives or agents, from all liability that may result from such an investigation. I authorize all individuals, schools, healthcare providers and firms named to provide any requested information and release them from all liability for providing the requested information in connection with my employment application. I also understand that I have the right to: Review the information provided by previous employers. Have errors in the information corrected by previous employers and have the corrected information re-sent to the prospective employer. 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. I understand this application will be active for a period of 90 days; after that time, if I wish to be considered for employment, I must submit a new application. I certify that this application was completed by me and that all statements in this completed application are true. I understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal to hire. I agree to abide by the rules and regulations of the employer and, if applicable, the Federal Motor Carrier Safety Regulations. I also agree and understand that if I am selected to work for the employer, I will be on an introductory period during which time I may be discharged without recourse.
Signature
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Date
(Required)
MM slash DD slash YYYY