Application for Employment

(Apply in person only)

Motor Propane Service, Inc.
5050 Center Road
Manitowoc, WI. 54221-0393

EMPLOYMENT RECORD Start with your last or current position (show employment for the past five years w/no gaps in history)
Current Employer	Contact Name
Address (City/State)	Telephone #
Position Held	From         /       to         /
Duties
Reason for Leaving		Salary
Please account for all gaps in employment
Past Employer	Contact Name
Address (City/State)	Telephone #
Position Held	From         /       to         /
Duties
Reason for Leaving		Salary
Please account for all gaps in employment
Past Employer	Contact Name
Address (City/State)	Telephone #
Position Held	From         /       to         /
Duties
Reason for Leaving		Salary
Please account for all gaps in employment
Past Employer	Contact Name
Address (City/State)	Telephone #
Position Held	From         /       to         /
Duties
Reason for Leaving		Salary

DRIVER EXPERIENCE & QUALIFICATION (Required for CDL Holders Only)
Driver Licenses held in past 3 years	State	License #	Class	Endorsements
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Has any license, permit or privilege ever been suspended or revoked? If Yes, explain why.
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? If Yes, explain why.

DRIVING EXPERIENCE (Required for CDL Holders Only)
Class of Equipment	Van, Tank, Flat, etc...	Years of Driving	Approximate Miles
Straight Truck
Tractor and Semi Trailer
List States Operated In:
List Special Courses or Training:
List any Awards:

ACCIDENT OR TRAFFIC CONVICTIONS (for past 3 years) (Required for CDL Holders Only)
Date	Type of Violation or Accident	Penalty or Outcome

REQUEST FOR CHECK OF DRIVING RECORD (Required for CDL Holders Only)
I hereby authorize you to release the following information to Motor Propane Service Inc. for purposes of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.
Applicant's Signature			Date
Name of Applicant (print)		Date of Birth
License #	S S #

RELEASE OF INFORMATION FROM PREVIOUS EMPLOYER AUTHORIZATION (All Applicants)
I hereby authorize my previous employers to release all information concerning my employment including oral assessments of my job performance, ability, and fitness to Motor Propane Service Inc. (or their authorized agents) that may request such information in connection with my application for employment with said company. I hereby release you from any and all liability of any type as a result of providing the requested information to the above authorized person or company.
Applicant's Signature	Date
Name of Applicant (print)	S S #

ALL APPLICANT MUST READ AND SIGN
I certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason. It is also agreed and understood that under the Fair Credit Report Act, Public law 91-508, I have been told that this investigation may including and investigative Consumer Report, including information regarding my character, general reputation, personal characteristics and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. I also understand that misrepresentation of omission of information or facts may result in my rejection or dismissal. If hired, I agree to abide by all the rules and policies of the employer. 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.
Applicant's Signature	Date

OFFICE USE ONLY
Date of Interview		Second Interview Date
Date of Hire		Start Date
Additional Training or Certifications Required
Notes