Sardinia Concrete::Sardinia Concrete Company

Employment Application

All fields labeled with an asterisk () are required*.
*First and Last Name:
*Social Security No.:
*Phone Number:
Alternate Phone No.:
*Email:
*Address:
*City:
*State:
*Zip:
*No. of years:
Previous Address (if less than 3 years):
City:
State:
Zip:
No. of years:

Experience & Qualifications (Driver)
Drivers License Information
1.	State Issued:
	License Number:
	Type (Class):
	Expiration:

2.	State Issued:
	License Number:
	Type (Class):
	Expiration:

3.	State Issued:
	License Number:
	Type (Class):
	Expiration:

4.	State Issued:
	License Number:
	Type (Class):
	Expiration:

Driving Experience
1.	Class of Equipment:	Straight Truck Semi-Tractor Trailer
	Class of Equipment:	Tractor Two-Trailer Other
	(Van, Tanker, Flat, Etc.):
	Dates (From/To):
	Approximate No. of Miles:

2.	Class of Equipment:	Straight Truck Semi-Tractor Trailer
	Class of Equipment:	Tractor Two-Trailer Other
	(Van, Tanker, Flat, Etc.):
	Dates (From/To):
	Approximate No. of Miles:

3.	Class of Equipment:	Straight Truck Semi-Tractor Trailer
	Class of Equipment:	Tractor Two-Trailer Other
	(Van, Tanker, Flat, Etc.):
	Dates (From/To):
	Approximate No. of Miles:

4.	Class of Equipment:	Straight Truck Semi-Tractor Trailer
	Class of Equipment:	Tractor Two-Trailer Other
	(Van, Tanker, Flat, Etc.):
	Dates (From/To):
	Approximate No. of Miles:

Accident Record (List from most recent)
1.	Date:
	Head-on, Rear-End, Etc.:
	Fatalities:
	Injuries:

2.	Date:
	Head-on, Rear-End, Etc.:
	Fatalities:
	Injuries:

3.	Date:
	Head-on, Rear-End, Etc.:
	Fatalities:
	Injuries:

4.	Date:
	Head-on, Rear-End, Etc.:
	Fatalities:
	Injuries:

Traffic Convictions and Penalties for Past 3 Years (Other than Parking Violation)
1.	Location:
	Date:
	Charge:
	Penalty:

2.	Location:
	Date:
	Charge:
	Penalty:

3.	Location:
	Date:
	Charge:
	Penalty:

4.	Location:
	Date:
	Charge:
	Penalty:

A. Have you ever been denied a license, permit or priviledge to operate a motor vehicle?
Yes No

B. Has any license, permit or privilege ever been suspended or revoked?
Yes No

If the answer to either A or B is yes, please give details:

Employment History
*NOTE: DOT requires that employment for at least 3 years and/or commercial driving experiences for the past 10 years be shown.
1.	*Current Employer:
	Address:
	Position Held:
	From:	To
	Salary:
	Reason for Leaving:

2.	*Employer:
	Address:
	Position Held:
	From:	To
	Salary:
	Reason for Leaving:

3.	*Employer:
	Address:
	Position Held:
	From:	To
	Salary:
	Reason for Leaving:

By submitting this application, applicant certifies that all entries and information given are true and complete to the best of applicants knowledge.