Home 9 Careers 9 Application-CDL Application (CDL) Step 1 of 11 9% Applicant InformationDate MM slash DD slash YYYY Full Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long have you lived at your current address? Phone*Email* Date Available Requested Pay Rate Position Applied for* Are you authorized to work in the US?* Yes No Have you ever worked for this company?* Yes No If yes, when? Have you ever been convicted of a felony involving the use of a commercial vehicle?* Yes No If yes, explain. EducationHigh School* Address Did you graduate?* Yes No Diploma College Address Did you graduate? Yes No Degree Other Address Did you graduate? Yes No Degree ReferencesPlease list three professional references.Full Name* Relationship* Company* Phone* Address Full Name Relationship Company Phone Address Full Name Relationship Company Phone Address Driving ExperienceAdd more rows by hitting the plus (+) icon to the right of the fields. Driving ExperienceClass of EquipmentType of Equipment (Van, Truck, Flat, Etc.)Dates (From-To)Approx. # of Miles (Total) Accident Record for the Past 3 YearsAdd more rows by hitting the plus (+) icon to the right of the fields. Accident Record for the Past 3 YearsDatesNature of Accident (Head-on, Rear-end, Etc.)# of Fatalities# of InjuriesChemical Spills? Traffic Convictions & Forfeitures for the Past 3 Years (other than parking violations)Add more rows by hitting the plus (+) icon to the right of the fields. Traffic Convictions & Forfeitures for the Past 3 YearDate Convicted (month/year)ViolationState of Violation LocationPenalty (forfeited bond, collateral and/or points) Additional InformationHave you ever been denied a license, permit, or privilege to operate a motor vehicle?* Yes No If “Yes”, please explain: Has any license, permit or privilege ever been suspended or revoked?* Yes No If “Yes”, please explain: Previous EmploymentCompany Phone Address Supervisor Job Title ResponsibilitiesListFromToReason for LeavingWere you subject to Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No Was your previous position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40? Yes No Company Phone Address Supervisor Job Title ResponsibilitiesListFromToReason for LeavingWere you subject to Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No Was your previous position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40? Yes No Company Phone Address Supervisor Job Title ResponsibilitiesListFromToReason for LeavingWere you subject to Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No Was your previous position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40? Yes No May we contact your previous supervisors for a reference? Yes No Please fill out the attached form and send to hr@lanracorp.com. Reference Checking Consent and Authorization Form Military ServiceMilitary ServiceBranchFromToTimeline of Service Rank at Discharge Type of Discharge If other than honorable, explain: Training & CertificationsDo you currently have OSHA Certification:?* Yes No If “Yes”, which type (IE, OSHA 10 or OSHA 30)? Do you have CURRENT pipeline safety training certification?* Yes No If “Yes”, what type(s)? Do you have current OQ Training?* Yes No If “Yes” when was your last testing date? How many years of work-related experience do you have with the following equipment? (Leave blank if no experience)Chain SawLine FinderSkid SteerAriel LiftAny other training or experience that correlates with this line of work? Recruiting QuestionsHow did you hear about Lanracorp?How did you hear about Lanracorp?* Heard about it on the radio Online Job Site (Indeed, state website, etc.) Social Media Newspaper Friend recommendation If recommended by a friend, what is their name? AssessmentHow many years of equipment operator/tree removal experience do you have?* Do you have a valid driver's license?* YES NO Are you willing to do a pre-employment drug and alcohol test?* YES NO Are you authorized to work in the US?* YES NO Are you willing to undergo a background check, in accordance w/ local laws/regulations?* YES NO Are you willing to travel for work?* YES NO Disclaimer and SignatureI authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (General 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, "I understand that information 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 om 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 other information. I understand that signing this application also serves an agreement to comply with this companies pre-employment drug and alcohol policies. I understand that employment will be offered on an at-will basis and that this application is only valid for 30 days of the signed date.Date* MM slash DD slash YYYY 69506
