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Smyrna Ready Mix Concrete
1136 Second Avenue North
Nashville, TN 37208

Employment Application

AN EQUAL OPPORTUNITY EMPLOYER

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Date of Application: 4/28/2017
Position(s) applied for:
Referral Source:
If Employee or Relative, please enter name below:

Per the requirements of the Federal Motor Carrier Safety Regulations (49 CFR 391.21), the following information is required:

Name:
Current Address:


Prior Address (Last 3 Years):


Date of Birth:
Social Security Number:
Home Phone:
Mobile/Other Phone:
Email Address:
May we contact your current employer?
May we contact you at work?
If yes, list work number and best time to call:
Are you legally eligible for employment in the United States?
Have you ever submitted an application here before?
If yes, give date(s) and position(s):
Date Available For Work:
Desired Salary/Pay Rate:
Type of employment desired:
Are you willing to relocate if job requires it?
Will you travel if job requires it?
Our schedules vary daily. Do you have a reliable means of getting to and from work on time?
Will you work overtime if required?
Have you ever pled “guilty” or “no contest” to, or have been convicted of a crime?
If Yes, please provide date(s) and details:

Employment History

Provide the following information of your past and current employers, assignments, military service, or volunteer activities, starting with the most recent (use additional sheets if necessary). Include 10 Years of history. Do Not Omit Any Positions. Explain any gaps in employment in the section provided.

Current or Most Recent Employer:
Start Date:
End Date:
Still Employed?
Phone Number:
Starting Wage:
Ending Wage:
Supervisor’s Name and Title:
Starting Job Title:
Ending Job Title:
Duties:
Reason for Leaving:
Type of Equipment Driven:
May we contact this Employer for reference?
Was your job subject to the Federal Motor Carrier Safety Regulations* while employed?
Next Previous Employer:
Start Date:
End Date:
Employer Address:
Phone Number:
Starting Wage:
Ending Wage:
Supervisor’s Name and Title:
Starting Job Title:
Ending Job Title:
Duties:
Reason for Leaving:
Type of Equipment Driven:
May we contact this Employer for reference?
Was your job subject to the Federal Motor Carrier Safety Regulations* while employed?
Next Previous Employer:
Start Date:
End Date:
Employer Address:
Phone Number:
Starting Wage:
Ending Wage:
Supervisor’s Name and Title:
Starting Job Title:
Ending Job Title:
Duties:
Reason for Leaving:
Type of Equipment Driven:
May we contact this Employer for reference?
Was your job subject to the Federal Motor Carrier Safety Regulations* while employed?
Explain any gaps in employment:

*The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size used to transport hazardous materials in a quantity requiring placarding.

Driving History and Qualifications

Section 383.21 FMSCR states “No person who operates a commercial motor vehicle shall at any time have more than one drivers license.” I certify that I do not have more than one motor vehicle license, the information for which is listed below.

State:
License #:
Type/Class:
Exp. Date:
Have you ever been denied a license, permit, or privilege to operate a vehicle?
Has your license, permit, or privilege ever been suspended or revoked?

List any Driver’s License held in the past three years below.

License #:
State:
Type/Class:
Exp. Date:
License #:
State:
Type/Class:
Exp. Date:
Accidents within the last 3 years?
If Yes, please list all Accidents below.
Accident Date: (#1)
Nature of Accident: (#1)
Location: (#1)
Fatalities/Injuries: (#1)
Hazardous Material Spill? (#1)
Accident Date: (#2)
Nature of Accident: (#2)
Location: (#2)
Fatalities/Injuries: (#2)
Hazardous Material Spill? (#2)
Accident Date: (#3)
Nature of Accident: (#3)
Location: (#3)
Fatalities/Injuries: (#3)
Hazardous Material Spill? (#3)

Please list all Convictions and Citations for the past Three Years other than parking violations:

Convicted Date: (#1)
Violation: (#1)
State of Violation: (#1)
Penalty: (#1)
Convicted Date: (#2)
Violation: (#2)
State of Violation: (#2)
Penalty: (#2)
Convicted Date: (#3)
Violation: (#3)
State of Violation: (#3)
Penalty: (#3)

Please list your Driving Experience

Type Of Equipment:
How Long: (#1)
Approximate Miles: (#1)
How Long: (#2)
Approximate Miles: (#2)
How Long: (#3)
Approximate Miles: (#3)

Skills and Qualifications

Indicate training and experience in the following:

Experienced In::
Formal Training: (#1)
Years of Experience: (#1)
Formal Training: (#2)
Years of Experience: (#2)
Formal Training: (#3)
Years of Experience: (#3)
List any other skills that would be of assistance in determining qualifications for employment:
List any professional, trade, or business associations and any offices held, as well as any special accomplishments, awards, etc. that are relevant:

Educational Background

School: (#1)
# Of Years Completed: (#1)
Degree or Diploma: (#1)
GPA: (#1)
Major: (#1)
Minor: (#1)
School: (#2)
# Of Years Completed: (#2)
Degree or Diploma: (#2)
GPA: (#2)
Major: (#2)
Minor: (#2)
School: (#3)
# Of Years Completed: (#3)
Degree or Diploma: (#3)
GPA: (#3)
Major: (#3)
Minor: (#3)

Reference

List name and telephone number of three work/business references who are NOT related to you.

Name: (#1)
Telephone: (#1)
Number of years known: (#1)
Name: (#2)
Telephone: (#2)
Number of years known: (#2)
I certify that all information I have provided in order to apply for and secure work with the Employer is true, complete, and correct. I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the Employer’s service, whenever it is discovered. I expressly authorize, without reservation, the Employer, its representatives, employees or agents to contact and obtain information form all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have regarding the Employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquires and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. “I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: -Review information provided by current/previous employers; -Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and -Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.”
I understand that the Employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the Employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the Employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the Employer’s president or vice-president. I understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that I will also be subject to a criminal background check. I also understand that before I will be made an official offer of employment, I must successfully pass a drug screen.

TRUCKING INDUSTRY: DOT D/A Disclosure and Authorization

PART 1 – DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES – 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to Smyrna Ready Mix Concrete, LLC Herein Called “SRM”. I understand that information/documents released pursuant to this Part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation. If any company listed below furnishes SRM with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to SRM, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years.

List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature.

Previous DOT - Regulated Employer: (#1)
City: (#1)
State: (#1)
Phone Number: (#1)
Previous DOT - Regulated Employer: (#2)
City: (#2)
State: (#2)
Phone Number: (#2)
Previous DOT - Regulated Employer: (#3)
City: (#3)
State: (#3)
Phone Number: (#3)
I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part 1 disclosure and authorization for release; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.
Print Applicant Name:
Social Security:
Date: 4/28/2017