CDL Application – McCoy Grading

What job are you applying for?*

Other

Name*

First Middle Last

Phone Number*

Email Address

Address*

Street Address City State / Province / Region ZIP / Postal Code

Driver License Number

Are you 18 or older?

Yes

No

Are you a citizen of the United States?

Yes

No

Do you have a valid drivers license?

Yes

No

If not, are you legally allowed to work in the United States?

Yes

No

Position Applying For

Rate of Pay Expected

How were you referred to us?

Date available to start?

Summarize your special skills or qualifications

Have you ever pleaded “guilty,” “no contest,” or been convicted of a crime?*

Yes

No

Answering “yes” does not constitute an automatic rejection for employment. Date of offense, seriousness and nature of the violation, rehabilitation and position applied for will be considered.

IF ANSWERED YES ABOVE, PLEASE FILL OUT SECTION BELOW:

Date*

Details*

EDUCATION

Highest grade completed?*

Last School Attended

Last School Address

WORK HISTORY

Start with the last or current position, including any military experience and work back. (attach a separate sheet if necessary)

Employer 1

Employer*

Supervisor*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone*

Position*

Salary*

From what dates did you work?*

Reason for leaving*

Employer 2

Employer

Supervisor

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Position

Salary

From what dates did you work?

Reason for leaving

Employer 3

Employer

Supervisor

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Position

Salary

From what dates did you work?

Reason for leaving

DRIVER EXPERIENCE AND QUALIFICATION

Answer the questions in this section only if you are applying for a driver position.

Physical History

The U.S. Department of Transportation requires that all driver applicants pass certain physical test before they are hired to drive a motor carrier.

Date of last Department of Transportation prescribed physical examination:

Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, leg, arm or hand?

Yes

No

Licenses

Driver Licenses held in the past 3 years must be shown

State

License Number

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, privilege ever been revoked or suspended?

Yes

No

C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?

Yes

No

If you answered “YES” to A, B, or C, email a statement giving details.

Driving Experience

Straight Truck

Type of Equipment (Van, Tank, Flat, etc.)

From Date

To Date

Approximate Total Miles

Tractor and Semi-Trailer

Type of Equipment (Van, Tank, Flat, etc.)

From Date

To Date

Approximate Total Miles

Twin Trailers

Type of Equipment (Van, Tank, Flat, etc.)

From Date

To Date

Approximate Total Miles

Other

Type of Equipment (Van, Tank, Flat, etc.)

From Date

To Date

Approximate Total Miles

List states operated in during the last 5 years

List special courses or training that will help you as a driver

List safe driving awards held and who awards were presented by

Accident Review for the past 3 years

Dates

Nature of Accident (Head-on, Rear-end, etc.)

Fatalities

Injuries

Traffic Convictions and Forfeitures for the past 3 years other than parking violations.

Location

Date

Charge

Penalty

Comments

Consent*

I certify the below information.*

I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquires of my personal, employment, educational, financial, and other related matters as may be necessary for an employment decision. I hereby release employers, schools or individuals from all liability when responding to inquires in connection with my application.

In the event I am employed, I understand that false and misleading information given in my application or interview(s) may result in discharge.

I hereby consent to submit to urinalysis and/or other tests as shall be determined by McCoy Grading, Inc. in the selection process of applicants for employment, for the purpose of determining the drug content thereof.

I agree that a lab designated by McCoy Grading, Inc. may collect these specimens for these tests and may test them or forward them to a testing laboratory designated by the company for analysis.

I agree that a diluted negative test result or any specimen that appears to be tampered with or suspicious will be treated as a positive test result and applicant will be responsible for the cost of the test, which is $110.00. The company will rely on the opinion of the testing laboratory as to the status of specimens submitted.

I further agree to and hereby authorize the release of the results of said test to the company.

I understand that it is the current use of illegal drugs that prohibits me from being employed at this company.

I further agree to hold harmless the company and its agents (including the above named physician or clinic) from any liability arising in whole or part, out of the collection of specimens, testing, and us of the information from the said testing connection with the company’s consideration of my application of employment.

I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original.

I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.

Equal Employment Opportunity

In order to provide equal employment and advancement opportunities to all individuals, employment decisions at McCoy Grading, Inc. will be based on merit, qualifications, and abilities. McCoy Grading, Inc. does not discriminate in employment opportunities or practices on the basis of race, color, religion, sex, national origin, age, disability, or any other characteristics protected by law.

McCoy Grading, Inc. will make reasonable accommodations for qualified individuals with known disabilities, unless doing so would result in an undue hardship. This policy governs all aspects of employment, including selection, job assignment, compensation, discipline, termination, and access to benefits and training. Any employees with questions or concerns about any type of discrimination in the workplace are encouraged to bring these issues to the attention of their immediate supervisor. Employees can raise concerns and make reports without fear of reprisal. Anyone found to be engaging in any type of unlawful discrimination will be subject to disciplinary action, up to, and including, termination of employment.