Join Our Team Introductory Information: Name : Phone: Date : Address: City: State: Zip: Applicant Question Type of work Desire: Salary Desired: Date Available: if hired, can you provide documents required to establish your eligibility to work in the U.S? YesNo Are you at-least 18 year of age? YesNo If you are under 18, and it is required, can you furnish a work permit? YesNo Do you have a valid Driver's Licence? YesNo How were you referred C.M. Nichols Landscaping / Maine Landscape Designs? Have you ever been convicted of, or pled guilty or no contest to, a crime rather than a minor traffic violation? YesNo If yes, please explain in details on a seperate piece of paper include the date of final deposition of the case and the nature of the offence. This information will not necessarily disqualify you from employment but false or misleading information will. Factor such as age and the offence, seriousness and the nature of the violation, and rehabilitation will be taken into account. Education High school or last grade completed: Name & Address of School: Course of Study: Last grade completed: Degree/Diploma: College or Technical school Name & Address of School: Course of Study: Last Grade Completed: Degree/Diploma : Other Schooling or Training Name & Address of School : Course of Study: Last Grade Completed: Degree/Diploma: Special Skills and Certifications: Summarize any Training, skills, licences and/ or certificates that may qualify you as being able to perform job related functions in the position for which are applying: MILITARY EXPERIENCE: Branch of Service: Rank/Type of Service : Job Related Training/Experience: RECORD OF EMPLOYMENT: List positions starting with most recent: Employer: Telephone: Address: Position Title: Supervisor Name/Email/Phone: Start date: Date Left: Beginning Salary: Ending Salary: Duties: Reason for Leaving: Where you subject to FMCRS while working for this company: YesNo Was your job with this company designated as a safety sensitive function subject to drug and alcohol testing requirement of 49 CFR: YesNo Employer: Telephone: Address: Position Title: Supervisor Name/Email/Phone: Start date: Date Left: Beginning Salary: Ending Salary: Duties: Reason for Leaving: Where you subject to FMCRS while working for this company: YesNo Was your job with this company designated as a safety sensitive function subject to drug and alcohol testing requirement of 49 CFR: YesNo Have you ever been denied a license, permit or privilege to operate a motor vehicle? YesNo Have any license, permit or privilege even been suspended or revoked? YesNo Please understand that information you provide regarding, current and previous employer may be used and those employer will be contacted for the purpose of investigating your safety performance history as required by 49 CFR 391.23 (d) and (E). The attached statement entitle- Due process rights (regarding information received as a result of investigations required by 49 CRF 391.23 (d) and (e) is being provided in accordance with 49 CRF 391.23 (i). I have read, understand and agree to the attached Due Process Statement YesNo Date: Printed Name: Due Process Rights Complete if you have driven a company vehicle subjected to FMCSR-Federal Motor Carrier Safety Administration Regarding information recived as a result of investigations required by 49 CFR 391,23(d) and (e) The right to review information provided by previous employers; The right to have errors in the iformation corrected by the previous employers and for that previous employers to re-send the corrected information to the prospective employers. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employers and the driver cannot agree on the accuracy of the information. Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employers-provided investigative information must submit a written request to the prospective employers, wich may be done ay any time, including when applying, or as late as 30 days after being employed or being notified of demial of employment The prospective employer must provide this information to the applicant within five(5) business days of receiving the written request. if the prospective employer has not yet received the requested information from the previous employer(s) then the five-business day deadline will being when the prospective employer received the requested safety perfomance history information. if the driver has not arranged to pick up or receive the requested records with in thirty (30) days of the prospective employer making then available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.