Kentuckiana Trucking, Inc.
 
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Employment Opportunities


Any Questions pertaining to job opportunities, contact Sean Schneider at 812.282.0908 or sean@kentuckianatrucking.com.

Personal Information

(Print and fill out the following form)

First Name:

Middle Name:

Last Name:

Address:

City:

State/Zipcode:

How long?(lived here)

Phone Number:

Social Security Number:

Height:

Weight:

Date of Birth:

Position Applied For:

Have you ever worked in this company before? If so, where?
Yes / No
   

Date From (mm/dd/yy):
/ /

To:
/ /

Rate of pay:

Position:

Reason for leaving:

 

Names of relatives in our employ:

Are you employed?
Yes / No

If not, how long since leaving your last employment?

PHYSICAL HISTORY

Date of last D.O.T Physical (mm/dd/yy):
/ /

EMPLOYMENT RECORD
Note: D.O.T. Requires that Employment for at least 3 years be shown

Last Employer
Name:

Address:

Phone Number:

Position Held:

From:
To:
Salary:

Reasons for leaving:

Second Last Employer
Name:

Address:

Phone Number:

Position Held:

From:
To:
Salary:

Reasons for leaving:

Third Last Employer
Name:

Address:

Phone Number:

Position Held:

From:
To:
Salary:

Reasons for leaving:

Fourth Last Employer
Name:

Address:

Phone Number:

Position Held:

From:
To:
Salary:

Reasons for leaving:

GENERAL INFORMATION

Have you ever been convicted of a felony?



If yes, please list them:

Have you ever been known by any other name other than the one on this application?



If yes, please list them:

EXPERIENCE AND QUALIFICATIONS

Driver Licenses
Please enter your drivers license information in the boxes below.
State License No. Type Expiration Date  
 


Have you ever been denied a license, permit or piviledge to operate a motor vehicle?
Yes / No

Has any license, permit or priviledge ever been suspended or revoked?
Yes / No

Have you ever been disqualified subject to section 391 of the Federal Motor Carrier Safety Regulations?
Yes / No

DRIVING EXPERIENCE

Class of Equipment Type of Equipment
(van, tank, flat, etc.)
From To Approx. No. of Miles
(total)
 
Straight Truck

 
Tractor and Semi-Trailer

 
Two Tractor Trailers

 
Other

 
List states operated in for last five years:
Show special courses or training that will help you as a driver:
Which safe driving awards do you hold and from whom?

ACCIDENT AND/OR VIOLATIONS REPORT FOR PAST 3 YEARS

Date

Nature of Accident or Violation
(head-on, rear-end, etc.)

Fatalities
Injuries
 


Applicant Email Address:

Applicant: Read before submitting this application:

The Age Discimination in Employment Act of 1967 prohibits
discrimination on the basis of age with respect to individuals
who are at least 40 but less than 70 years of age.

I understand that the information in this application will be used and that prior employers
will be contacted for purposes of investigation as required by 391.23 of the
Federal Motor Carrier Safety Regulations.

Signature:

Enter numbers in Verify field
Verifaction Code