Application for Employment (Apply in person only)

Motor Propane Service, Inc.
5050 Center Road
PO Box 393
Manitowoc, WI 54221-0393
920-758-2919

Name of Applicant
(First/Middle/Last)		   Date  
Current Address
(City/State/Zip)		  
Phone Number   E-mail Address  
Social Security #   Date of Birth  
Position Desired   Expected Rate of Pay  

EDUCATION/TRAINING
Indicate Highest Grade Completed   Last School Attended
(Name and City/State)		  
Special Courses of Study:  
Training or Skills
(even if not related to position applying for)		  

GENERAL
Have you ever been bonded? If so, the name of the bonding company.  
Have your ever been convicted of a felony?
If yes, please explain fully. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.		  
Who to notify in case of an emergency
Name/Phone/Relationship		  
How did you hear about this opening?  
Are you available:

How many hours per week?
Time of day available

 Full Time
Part Time  _____ Hours
Weekends
Have you ever worked for this company before?  
Are there any special needs that you have that must be considered and accommodated to aid you in performing your job duties.  
If hired, date able to start.  

Please continue on and complete the application fully and accurately. Missing information will result in your application being suspended from processing. All applications are kept for six months. We reserve the right to contact you in the future should other openings occur.

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

DRIVER EXPERIENCE & QUALIFICATION
Drivers 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?  
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?  

If you answered yes to any of the above questions attach a sheet giving details.

DRIVING EXPERIENCE
Class of Equipment Van, Tank, Flat, etc. Years of Driving Approximate Miles
Straight Truck      
Tractor and Semi Trailer      
List States Operated In      
List Special Course or Training      
List any Awards  

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

REQUEST FOR CHECK OF DRIVING RECORD
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 Signature   Date
Name of Applicant (print)   Date of Birth  
License #   Social Security #  
Requested by   Date  

RELEASE OF INFORMATION FROM PREVIOUS EMPLOYER AUTHORIZATION
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 Signature   Date  

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 include an 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 or 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 Signature   Date  

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