Twin Cities Ready Mix, Inc.

Application For Employment


APPLICANT: READ AND SIGN BEFORE SUBMITTING THIS APPLICATION
	
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 Motor Carrier Safety Regulations.
		
	_____________________________________       _________________________
	Signature of Applicant			    Date

First name Middle Last name Maiden name Phone number Social Security number Date of birth Address City State Zip How long? Address for the past three years: Address City State Zip How long? Address City State Zip How long? (Attach sheet if more space is needed) Check one: Single Engaged Married Separated Divorced Widowed In case of emergency notify Phone Address City State Zip Position applying for Plant location Temporary Permanent Have you ever worked for this company before? No Yes If yes, where? Dates: From To Rate of Pay Position Reason for leaving Names of relatives in our employ Are you employed now? Yes No If not, how long since leaving last employment? Who referred you Rate of expected pay Is there any reason why you might be unable to perform the functions of the job for which you are applying? No Yes If yes, explain if you wish: EMPLOYMENT RECORD (attach sheet if more space is needed) Note: D.O.T. requires that employment for at least 10 years be shown Employer name Phone # Address Position held From To Salary Reason for leaving Employer name Phone # Address Position held From To Salary Reason for leaving Employer name Phone # Address Position held From To Salary Reason for leaving Employer name Phone # Address Position held From To Salary Reason for leaving Employer name Phone # Address Position held From To Salary Reason for leaving MILITARY STATUS Have you ever served in the U.S. Armed Forces? Yes No Branch Dates: From To Rank at discharge Date of discharge (If in NJ do not fill in the next line unless hired) Draft status Reserve status EDUCATION Highest grade completed 1 2 3 4 5 6 7 8 High school 9 10 11 12 College 1 2 3 4 Last school attended City GENERAL Have you ever been bonded? Yes No Name of bonding company Have you ever been refused bond? Yes No If yes, why? Have you ever been convicted of any crime? Yes No If yes, what? Have you ever been known by any other name other than the one on this application? Yes No If yes, what? ACCIDENT RECORD FOR THE PAST THREE YEARS OR MORE (attach sheet if more space is needed)

Dates	Nature of Accident (head-on,rear-end,upset,etc.)	Fatalities	Injuries
Last accident
Next previous
Next previous

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST THREE YEARS (other than parking violations)
(attach sheet if more space is needed)

Location	Date	Charge	Penalty

EXPERIENCE AND QUALIFICATIONS - DRIVER

Drivers licenses held in the past 3 years must be shown	State	License No.	Type	Expiration Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No B. Has any license, permit or privilege ever been suspended or revoked? Yes No C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes No If you answered "Yes" to either A,B, or C, attach a statement giving details. DRIVING EXPERIENCE

Class of Equipment	Type of Equipment (van, tank, flat, etc.)	Dates From To	Approx. No. of Miles (Total)
Straight Truck
Tractor and Semi-Trailor
Tractor-Two Trailors
Other

List states that you have operated in for the last five years EXPERIENCE AND QUALIFICATIONS - MAINTENANCE List types of maintenance experience and years of each

Equipment You Can Operate	Formal Training	Years Exp.	Equipment	Formal Training	Years Exp.
Woodworking equipment			Electric welder
Sheet metal equipment			Oxyacetylene welder
Clutch rebuilding			Paint spray gun
Differential rebuilding			Wheel & tire balancing machine
Transmission rebuilding			Tire recapping mold
Body work			Engine dynamometer
Frame & axle straightening equipment			Chassis dynamometer
Electrical & ignition repair			Magnetic crack tester
Engine rebuilding equipment			Vacuum & air brakes
Diesel injection equipment			Smoke measuring equipment
Inspections			Other:

List courses and training in maintenance work EXPERIENCE AND QUALIFICATIONS - CLERICAL

Equipment You Can Operate	Training	Years Exp.	Equipment You Can Operate	Training	Years Exp.
Typing WPM			Rates
Shorthand WPM			OS & D
Billing			Interline
TWX			Claims
PBX			Cashier
Key punch operator			Accounting
Calculator			Dispatcher
Dictating machine transcriber			Tabulator
Bookkeeping machine			Mimeograph
Adding machine			**Indicate tariffs with which you have worked
Other:			**Indicate tariffs with which you have worked

Please read the following statements carefully prior to signing this application

I, , hereby apply for employment with Twin Cities Ready Mix, Inc. (hereinafter referred to as EMPLOYER). I specifically verify that all the information provided in this application for employment is true, complete, and correct. I understand and agree that the omission or misrepresentation of any fact in the application for employment will be sufficient reason for EMPLOYER to deny me employment. I also understand and agree that should I become employed by EMPLOYER and it is later discovered I have omitted or misrepresented any fact in this application for employment, in any supplement thereto, or any other corporate record, EMPLOYER may immediately terminate my employment upon discovery of such omission or misrepresentation. I will abide by the safety rules of this company. If injured, I authorize my employer to use best judgement for treatment unless I instruct otherwise. Applicant's Signature___________________________Date___________This application expires 30 days from this date.