Gold-Eagle Cooperative - CDL Application

What is your contact info?

First Name

Last Name

Street Address

City

State

Zip Code

Home Phone

Email

Cell Phone

Drivers License Number

Position Applying For:

Position Type:

Full Time

Part Time

Seasonal / Internship

Available to Work:

Days

Evenings

Weekends

Have you ever applied for employment with us?

Yes

No

Apart from absence for religious observance, are you available for full-time work?

Yes

No

Will you work overtime if asked?

Yes

No

Are you legally eligible for employment in the United States?

Yes

No

EDUCATION

School #1

Name of School

City

State

Grade Completed

Did you graduate?

Yes

No

Major

School #2

Name of School

City

State

Grade Completed

Did you graduate?

Yes

No

Major

School #3

Name of School

City

State

Grade Completed

Did you graduate?

Yes

No

Major

Have you ever been convicted of or pled guilty to a crime?

Yes

No

Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, handicap or veteran status.

EMPLOYMENT HISTORY

Past Employer #1

Company Name

City

State

Phone

Supervisor Name:

OK to Contact:

Yes

No

Employed From:

Employed To

Job Title:

Starting Pay Rate:

Ending Pay Rate:

Reason for Leaving:

Past Employer #2

Company Name:

City

State

Phone

Supervisor Name:

OK to Contact:

Yes

No

Employed From:

Employed To:

Job Title:

Starting Pay Rate:

Ending Pay Rate:

Reason for Leaving:

Past Employer #3

Company Name:

City

State

Phone

Supervisor Name:

OK to Contact:

Yes

No

Employed To:

Job Title:

Starting Pay Rate:

Ending Pay Rate:

Reason for Leaving:

List accidents within the last 3 years. Please list the nature of the accident, number of fatalities, number of injuries, and whether it was a haz-mat spill.

Please list all Traffic Convictions in the last 3 years. Please list the Date Convicted, Violation, State of Violation, 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, the information for which is listed below.

State

License Number

Expiration Date

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

Yes

No

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

Yes

No

Please list your driving experience in the last 3 years. Please include the Class of Equipment, Type of Equipment, Dates, and Approximate Number of Miles.

Experience and Qualifications - Other

Show any trucking, transportation, or other experience that may help in your work for this company.

List courses and training other than shown elsewhere in this application.

Have you received any safe driving awards and from whom?

Gold-Eagle Cooperative/CORN, LP

Applicant Notification and Release

As part of our hiring background and investigation, we may obtain consumer reports to prepare an investigative consumer report. The investigative consumer report may consist of contacting all listed prior employers to verify your employment history. It may also include, but not be limited to, credit information reports, criminal history reports and driving history records. Under the provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before we can seek such reports, we must have your written permission to obtain the information. You have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation. You are also entitled to a copy of your Rights Under the Fair Credit Reporting Act.

Under the provisions of the Fair Credit Reporting Act, 15 USC, Section 1681 et seq., the Americans with Disabilities Act and all applicable federal, state, and local laws, I hereby authorize and permit Gold-Eagle Cooperative / CORN, LP to obtain a consumer report and/or an investigative consumer report which may include the following:

My employment records; Records concerning any driving, criminal history, credit history, civil record, workers’ compensation (post-offer only) and drug testing; (For truck drivers only) In accordance with the Department of Transportation Motor Carrier Safety Regulations, Section 382.413, information concerning alcohol and controlled substances for the past 2 years; Verification of my academic and/or professional credentials; and information and/or copies of documents from any military service records.

I understand that an “investigative consumer report” may include information as to my character, general reputation, personal characteristics, and mode of living which may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information.

I agree that a copy of this authorization has the same effect as an original.

hereby release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization, as well as Gold-Eagle Cooperative / CORN, LP from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information.

I understand and acknowledge that under provision of the Fair Credit Reporting Act I may request a copy of any consumer report from the consumer reporting agency that compiled the report, after I have provided proper identification.

I hereby authorize Gold-Eagle Cooperative / CORN, LP to obtain and prepare an investigative consumer report as set forth above, as part of its investigation of my employment application. This authorization shall remain in effect over the course of my employment. Reports may be ordered periodically during the course of my employment.

Full Name

Drivers License Number

Applicant's Date of Birth (month/day/year)

Required field