Employment Application
Hale Multimedia LLC - Designers of more than 300 websites in 20 States and 3 Countries.
JBC, Inc.
Jack & Brian Copsey
P.O. Box 1468, 1414 E. 20th St., Ste. 6
Scottsbluff, NE 69361
(308) 635-0455
 
February 06, 2012
Position(s) applied for :  
Your Name :
Last Name
First Name
Middle Name
Social Security
Address :
Street
Phone
 
City
State
Zip Code
How Long?
 
Previous Addresses :

Street
City
State
Zip Code
How Long?

Street
City
State
Zip Code
How Long?

Street
City
State
Zip Code
How Long?
 
Do you have the legal right to work in the United States?  
Birth Date : YYYY-MM-DD Can you provide proof of age?  
 
Have you worked for JBC before?   Where?  
Position :  
Dates : MM-YYYY From : To : Rate of Pay :
Reason for Leaving :
 
Are you now employed?   If not, how long since last employment?  
Who referred you?   Rate of Pay expected :  
Is there any reason you might be unable to perform the functions of the job for which you have applied?  
If yes, explain
if you wish. :
 
EMPLOYMENT HISTORY

   All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code.

   Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent.)

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
 
Employer 1 Date : MM-YYYY
Name :   From : To :
Address :   Position :  
City :    State :    Zip :  Wage :  
Contact Person :   Phone :  
Reason for Leaving :
 
Employer 2 Date : MM-YYYY
Name :   From : To :
Address :   Position :  
City :    State :    Zip :  Wage :  
Contact Person :   Phone :  
Reason for Leaving :
 
Employer 3 Date : MM-YYYY
Name :   From : To :
Address :   Position :  
City :    State :    Zip :  Wage :  
Contact Person :   Phone :  
Reason for Leaving :
 
Employer 4 Date : MM-YYYY
Name :   From : To :
Address :   Position :  
City :    State :    Zip :  Wage :  
Contact Person :   Phone :  
Reason for Leaving :
 
Employer 5 Date : MM-YYYY
Name :   From : To :
Address :   Position :  
City :    State :    Zip :  Wage :  
Contact Person :   Phone :  
Reason for Leaving :
 
Employer 6 Date : MM-YYYY
Name :   From : To :
Address :   Position :  
City :    State :    Zip :  Wage :  
Contact Person :   Phone :  
Reason for Leaving :
 
Employer 7 Date : MM-YYYY
Name :   From : To :
Address :   Position :  
City :    State :    Zip :  Wage :  
Contact Person :   Phone :  
Reason for Leaving :
 
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE. IF NONE, WRITE NONE
(NOTE: List in reverse order starting with the most recent.)
 
DATES NATURE OF ACCIDENT
(Head-on, Rear-end, Upset, Etc.)		 FATALITIES INJURIES
 
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
IF NONE, WRITE NONE. (NOTE: List in reverse order starting with the most recent.)
 
DATE LOCATION CHARGE PENALTY
 
EDUCATION
HIGHEST GRADE OR YEAR COMPLETED : Grade School : High School : College :
Last School Attended : Name : City, ST :
 
EXPERIENCE AND QUALIFICATIONS
DRIVER LICENSES STATE LICENSE NO. TYPE EX. DATE
 
 
 
 
 
 
Have you ever been denied a license, permit or privelege to operate a motor vehicle?  
If yes, give details :
Has any license, permit or privilege ever been suspended or revoked?  
If yes, give details :
 
DRIVING EXPERIENCE - IF NONE, WRITE NONE
CLASS OF EQUIPMENT TYPE OF EQUIPMENT
(van,tank,flat,etc.)		 DATES
(From - To)		 APPROX. NO. OF MILES
(Total)
STRAIGHT TRUCK  
TRACTOR & SEMI- TRAILER  
TRACTOR - TWO TRAILERS  
MOTORCOACH / SCHOOL BUS  
OTHER  
 
LIST STATES OPERATED IN FOR LAST FIVE YEARS
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?  
 
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR JBC INC
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (other than those already shown)
 
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. My email address serves as a temporary signature pending employment.
   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 inquiries 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.
Applicant’s Name :   Email Address :


In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.