Skillett & Sons, Inc
P.O Box 196,  Rush Center, KS 67575
The purpose of this application is to determine whether or not the applicant is qualified
to operate motor carrier equipment according to the requirements of the 
Federal Motor Carrier Safety Regulations and the Company named above.
 
 

Applicant Information

Please answer all questions.  If the answer to any question is "No" or "None", do not leave the item blank, but write "No" or "None".
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Position Applying For:

Best time to call/contact:
Have you worked for this company before?
*The Age Discimination of 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.
Is your license a Class A CDL?

Education History

Please select the highest grade completed:

Employment History (past 3 years)

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Were you subject to the FMCSRs* while employed here?
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
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Were you subject to the FMCSRs* while employed here?
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
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Were you subject to the FMCSRs* while employed here?
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
**If work history does not show proof of 3 years prior employment you may be asked to provide addition information
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.

Driving Experience

Class of Equipment
 Dates From - Dates To
Straight Truck
 Dates From - Dates To
Tractor -Semi-trailer
 Dates From - Dates To
Tractor -two trailers
 Dates From - Dates To
Tractor - triples
 Dates From - Dates To
Other
Has any license, permit or privilege ever been suspended or revoked?
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Any reason you might be unable to perform the functions of your job duties?
Have you ever been convicted of a felony?

To Be Read and Signed by Applicant

It is agreed and understood that any misrepresentation given on this application shall be consedered an act of dishonesty.  It is agreed and understood that the motor carrier 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 applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information.  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 investigating Consumer Report, including information regarding my character, general 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 application file. It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant.
It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
 
       **Additional release forms will be submitted to the applicant upon qualification**
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Applicants Signature *
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