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People's Electric Cooperative
Ada, Oklahoma
DRIVER'S SUPPLEMENTAL
APPLICATION FOR EMPLOYMENT
DATE FILED : 12/18/18
Name
(First) (Middle) (Maiden Name, if any) (Last)
Address
(Street) (City) (State & Zip Code) How long?
Date of Birth Social Security Number
Information received in response to the request for your date of birth will not be used to discriminate on the basis of age against any applicant for employment or employee. Such information is requested to comply with the requirements of 49 C.F.R. ยง 391.21(b)(2).
Address for Past Three Years:
(Street) (City) (State & Zip Code) How long?
(Street) (City) (State & Zip Code) How long?
Driver's
License
State License No. Type Expiration Date
Driving Experience:
Class of Equipment Type of Equipment
(Van, Flat, Tank, etc.)
Dates Approx. No. of Miles (Total)
To Form
Straight Truck
Tractor & Semi-Trailer
Tractor - Two Trailers
Other:
Accident Record For Past Three Years:
Date Nature of Accident
(Head-on, Rear-end, Upset, ect.)
Fatalities Injuries
Last Accident
Previous Accident
Previous Accident
Previous Accident
TRAFFIC CONVICTIONS AND FOREFEITURES FOR THE PAST THREE YEARS (OTHER THAN PARKING VIOLATIONS):
Location Date Charge Penalty
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? YesNo
B. Has any license, permit, or privilege ever been suspended or revoked? YesNo
IF THE ANSWER TO EITHER A OR B IS YES, ATTACH A STATEMENT GIVING DETAILS
Employment Record (Attach Sheet if More Space is Needed)
Note: DOT requires that employment for at least three years be shown. If applying for a position that requires you to have a commercial driver's license, you must list your employment in which you drove commercial motor vehicles for the last ten years. The information provided in this section may be used for the purpose of investigating your work history, and previous employees listed here may be contacted.
LAST EMPLOYER: Name:
Address:
Position Held:FromToSalary
Reasons for Leaving:
SECOND LAST EMPLOYER: Name
Address:
Position Held:FromToSalary
Reasons for Leaving:
THIRD LAST EMPLOYER: Name
Address:
Position Held:FromToSalary
Reasons for Leaving:
TO BE READ AND SIGNED BY APPLICANT
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.
Date Applicant's Signature
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.