G & S Home and Shelter Services Application
Please read and answer the questions to the best of your ability.
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Email *
Date *
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Applicant Name  (Whole name) *
Home Phone
Cell Phone
Current Address *
City, State, Zip code *
If the above residence less than three years, list below all residences for the past three years. Attach a separate sheet if necessary
Position Applying for
Temporary? *
Part Time? *
Full Time *
Who referred you?
Rate of Pay Expected?
Have you ever worked for this company before? *
If you have, when?   From- To
Rate of Pay?
Position
Reason for leaving
Name of any relatives by this company
Are you currently employed? *
If not, how long since leaving last employment?
EDUCATION
Check highest grade completed.
Clear selection
Last School Attended (Name and Address)
Military Experience
Have you ever served in the U.S. Armed Forces? *
If yes, which branch?
Describe any military training received relevant to the position for which you are applying.
Are you currently serving in Military Reserves? *
Are you currently serving in National Guard? *
General
Have you ever been bonded?  (Answer only if a job requirement)
Clear selection
Name of bonding company
Have you ever been convicted of a felony? *
If yes, please explain below. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.
DRIVER EXPERIENCE AND QUALIFICATIONS
The Federal Motor Carrier Safety Regulations (49CFR391.21 (b) (2) requires that driver applicants state their date of birth and SS #
Date of Birth *
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Social Security Number *
Physical History
The Federal Motor Carrier Safety Regulations (49CFR391 Subpart E) requires that all driver applicants pass certain physical tests before
they are hired to drive a motor vehicle.
Date of last Department of Transportation prescribed examination.
MM
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Can you provide a copy? *
Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, leg, hand or arm? *
ALCOHOL AND CONTROLLED SUBSTANCE STATEMENT
The Federal Motor Carrier Safety Regulations 49CFR40.25(j) requires all persons with applying for a driving position requiring a commercial
drivers license to answer the following questions:

Within the last two years, have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain safety-sensitive transportation work? *
 Within the last two years, have you ever tested positive, or refused to test, on any type of drug or alcohol test administered by an employer for which you performed safety-sensitive transportation work? *
 If you answered yes to either 1 or 2 above, can you provide and/or obtain proof that you have successfully completed the DOT return-to-duty requirements? *
Applicants Electronic Signature *
Date: *
MM
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DRIVER’S LICENSE INFORMATION
DRIVERS LICENSE HELD IN THE PAST 3 YEARS

State
License number
Type
Expiration Date
State
License number
Type
Expiration Date
State
License number
Type
Expiration Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle? *
Has any license, permit or privilege ever been suspended or revoked? *
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulation?  
Clear selection
If you answered “Yes” to A, B, or C, attach a statement giving details.
DRIVING EXPERIENCE
Class of Equipment.
Clear selection
Type of Equipment (Van, Tank, Flat,etc.)
Dates     (From-To)
Approximate Total Miles
Class of Equipment (if you drove more than one)
Clear selection
Type of Equipment (Van, Tank, Flat,etc.)
Dates     (From-To)
Approximate Total Miles
Class of Equipment
Clear selection
Type of Equipment (Van, Tank, Flat,etc.)
Dates     (From-To)
Approximate Total Miles
Class of Equipment
Clear selection
Type of Equipment (Van, Tank, Flat,etc.)
Dates     (From-To)
Approximate Total Miles
DRIVER EXPERIENCE AND QUALIFICATION (continued)
ACCIDENT HISTORY
Accident Review for the past 3 years (attach a separate sheet of paper if more space is needed)
Date
MM
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DD
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YYYY
Nature of  Accident (Head-On, RearEnd, Upset, etc)
# Fatalities
# Injuries
# Vehicles Towed
Citation Issued
Date
MM
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DD
/
YYYY
Nature of  Accident (Head-On, RearEnd, Upset, etc)
# Fatalities
# Injuries
# Vehicles Towed
Citation Issued
Date
MM
/
DD
/
YYYY
Nature of  Accident (Head-On, RearEnd, Upset, etc)
# Fatalities
# Injuries
# Vehicles Towed
Citation Issued
MOTOR VEHICLE DRIVING RECORD (MVR)
Traffic Convictions and Forfeitures for the past 3 years other than parking violations.

Date
MM
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DD
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YYYY
Location
Charge
Penalty
Date
MM
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DD
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YYYY
Location
Charge
Penalty
Date
MM
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DD
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YYYY
Location
Charge
Penalty
Employment Record
The Federal Motor Carrier Safety Regulations (49CFR391.21) require that all applicants wishing to drive a commercial vehicle list all
employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history
for an additional seven (7) years for a total of ten (10) years. Any gaps in employment must be explained.

Current Employer
Supervisor's Name
Address
Phone
Position Held
From-To
Salary
Reason for leaving
Previous Employer
Supervisor's Name
Address
Phone
Position Held
From-To
Salary
Reason for leaving
Previous Employer
Supervisor's Name
Address
Phone
Position Held
From-To
Salary
Reason for leaving
I certify that I have read and understood all of this employment application. It is agreed and understood that the employer or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and the applicant releases employers and other persons named herein from all liability for any damages on account of his furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks that are pertinent to the job.It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, personal reputation, personal characteristics, and mode of living.I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.If hired, I agree to abide by all the rules and policies of the employer. This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of  my knowledge.                                                                               Electronic sign your whole name below. *
Date *
MM
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DD
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A copy of your responses will be emailed to the address you provided.
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