Employment Application

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Step 1 of 8 - Personal

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Personal Information
Incomplete information may disqualify you from further consideration.
Name*
First Middle Last
Position desired?*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Do you possess an active Driver's License*
- Yes
- No
Home Phone*
Provide at least one phone number where you can be reached.
Mobile Phone
Other Phone
Work Eligibility
Are you eligible to work in the U.S?*
- Yes
- No
Are you at least 18 years or older?*
- Yes
- No
(If no, you may be required to provide authorization to work.)
Can you work any shift?*
- Yes
- No
Can you work overtime, including weekends?*
- Yes
- No
Are you able to travel out of town, overnight, for extended periods of time?*
- Yes
- No
Have you ever been terminated from employment or asked to resign by an employer?*
- Yes
- No
If yes, please provide company names and details.*
Do you have any felony convictions?*
- Yes
- No
If yes, please explain and include approximate date(s):*
We run background checks and honesty counts. Circumstances of convictions can be considered if listed here.

Job Details
Incomplete information may disqualify you from further consideration.
Hourly Rate / Salary desired?*
Date you can start*
MM slash DD slash YYYY
Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?*
- Yes
- No
Are you currently employed?*
- Yes
- No
If so, may we inquire of your present employer?*
- Yes
- No
If No, how long since your last employment?*
Referral Source
How did you hear about us?*
- Walk In
- Advertisement
- Referral
- Internet Search
- Employment Agency
Name of referrer?*
Have you ever applied to work at Central Seal before?*
- Yes
- No
If yes, when?*
Have you ever worked for Central Seal before?*
- Yes
- No
If yes, please provide start and end dates*
Who was your immediate supervisor?
Do you know anyone who works for Central Seal?*
- Yes
- No
Please list name and relationship.*

Education
Incomplete information could disqualify you from further consideration.

Fill in the applicable education and training below.
High School
School Name
Location
Number of Years Attended
Please enter a number from 0 to 99.
Degree Recieved
- Yes
- No
Subjects Studied / Vocational Traning
College or University
School Name
Location
Number of Years Attended
Please enter a number from 0 to 99.
Degree Recieved
- Yes
- No
Subjects Studied / Major
Trade, Business, or Correspondence School
School Name
Location
Number of Years Attended
Please enter a number from 0 to 99.
Degree Recieved
- Yes
- No
Subjects Studied / Major
Please list any relevant experience, licenses, training or certifications that you have that may be used in carrying out your job duties if hired.

Employment History
Include your last seven (7) years of employment history, including periods of unemployment, starting with the most recent and working backwards in time.

Incomplete information could disqualify you from further consideration. IMPORTANT: The U.S.D.O.T requires driver applicants to show all employment for the past 3 years and all commercial driving employment for the past 10 years. FMCSR 391.21(b)(10),(11).
Display Employment History Forms
- Current or Previous Employer
- Previous Employer Two
- Previous Employer Three
Select which employment forms are need below.
Current or Previous Employer
Incomplete information could disqualify you from further consideration.
Company Name*
From*

(MO / YR)
To*

(MO / YR)
Position Held*
Job Description*
Salary/Wage
Reason for Leaving*
Supervisor Name*
Employer Phone*
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Was this position designated as a safety-sensitive function subject to DOT-Regulated drug and alcohol testing?*
- Yes
- No
While employed by this employer, were you subject to the FMCSRs?*
- Yes
- No
Previous Employer Two
Incomplete information could disqualify you from further consideration.
Company Name*
From*

(MO / YR)
To*

(MO / YR)
Position Held*
Job Description*
Salary/Wage
Reason for Leaving*
Supervisor Name*
Employer Phone*
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Was this position designated as a safety-sensitive function subject to DOT-Regulated drug and alcohol testing?*
- Yes
- No
While employed by this employer, were you subject to the FMCSRs?*
- Yes
- No
Previous Employer Three
Incomplete information could disqualify you from further consideration.
Company Name*
From*

(MO / YR)
To*

(MO / YR)
Position Held*
Job Description*
Salary/Wage
Reason for Leaving*
Supervisor Name*
Employer Phone*
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Was this position designated as a safety-sensitive function subject to DOT-Regulated drug and alcohol testing?*
- Yes
- No
While employed by this employer, were you subject to the FMCSRs?*
- Yes
- No

Vehicle History
Indicate training, experience, and certifications you have received in the following areas:
Have you ever traveled as part of your job?*
- Yes
- No
If yes, for whom?*
Can you drive a manual or "stick" shift?*
- Yes
- No
Do you currently have a commercial driver's license or CDL permit?*
- Yes
- No
If yes, what class is your license?*
Do you understand what a "CDL" is and what is required to get one?*
- Yes
- No
Please list all vehicle types, equipment, and machinery that you have drivers experience with: (example: boxtruck, forklift, semi, etc.)
Accident Review for the Past 3 Years
Please provide details and information below if you have had an accident in the past three (3) years.
Have you had an accident in the past three years?*
- Yes
- No
If yes, explain.
Traffic Convictions and Forfeitures
Please provide details and information below if you have had any traffic violations during the past 3 years (Do not include parking tickets)
Have you had any traffic violations during the past 3 years which resulted in conviction or forfeiture? Especially DUI and reckless driving.*
- Yes
- No
If yes, explain.

Regulated Drug & Alcohol Screening History
Employers subject to Federal Motor Carrier Safety Regulations must ask prospective employees about their drug and alcohol screening history during the preceding 3-year period.
During the preceding 3 years, have you worked for an Employer that was DOT Regulated?*
- Yes
- No
During the preceding 3 years, have you held a job that was designated as a "Safety Sensitive Function" in any DOT-regulated mode subject to alcohol and drug testing requirements as required by 49 CFR Part 40 of the FMCSA regulations?*
- Yes
- No
During the preceding 3 years, have you tested positive, or refused to participate in, a drug or alcohol test administered by an employer subject to Federal Motor Carrier Safety Regulations? [A refusal includes accepting employment termination rather than participating in a test, or substituting, or otherwise tampering with a sample.]*
- Yes
- No
Have you ever been denied a job with an employer subject to Federal Motor Carrier Safety Regulations because you tested positive, or failed to participate in a pre-employment drug or alcohol test?*
- Yes
- No
If you answered "YES" to question #1 and/or #2, you must provide a consent form, authorizing each former employer that met the conditions #1 and or #2, to release your Safety Performance History. You must provide that employers contact information (Address, Telephone #, Fax #).

If you answered "YES" to questions #3 or #4, you must provide documentation of succesful completion of DOT's return-to-duty process before we can employ you
Signature*
Name Date
Previous Employment with DOT-Regulated Employers (Previous 3 Years)
Federal Motor Carrier Safety Regulations require prospective employers to request information from driver applicants concerning their experience driving commercially and/or working for DOT-regulated employers.

Please complete the statement below, sign and date it.
Have you worked for DOT-Regulated employer during the preceding 3 years?*
- I have worked for a DOT-Regulated employer
- I have not DOT-Regulated driving history nor DOT-Regulated Drug and Alcohol history to investigate for the preceding 3-year period.
Signature*
Name Date
The U.S.D.O.T. requires driver applicants to pass certain physical test before they are hired to drive for a motor carrier. FMCSR 391(E)
Date of last Department of Transportation prescribed physical examination:
MM slash DD slash YYYY
Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of a foot, leg, hand, or arm?
- Yes
- No
Signature*
Name Date Date of Birth
Health Affidavit
Do you have any type of illness or injury that may affect your ability to perform any essential functions of your job including heart related illnesses? If yes, please explain.*
Signature*
Name Date

References
Give the names of three professional references, not related to you, whom you have known and/or worked with previously.

Please provide a minimum of three (3) personal references.
Display Reference Forms*
- Reference One
- Reference Two
- Reference Three
Select which reference forms are need below.
Reference One
Incomplete information could disqualify you from further consideration.
Name*
First Last
Company Name
Years Acquainted*
Please enter a number from 0 to 99.
Describe relationship.
Phone*
Email
Address
Street Address Address Line 2 City State ZIP Code
Reference Two
Incomplete information could disqualify you from further consideration.
Name*
First Last
Company Name
Years Acquainted*
Please enter a number from 0 to 99.
Describe relationship.
Phone*
Email
Address
Street Address Address Line 2 City State ZIP Code
Reference Three
Incomplete information could disqualify you from further consideration.
Name*
First Last
Company Name
Years Acquainted*
Please enter a number from 0 to 99.
Describe relationship.
Phone*
Email
Address
Street Address Address Line 2 City State ZIP Code

Resume
Max. file size: 300 MB.
(Optional)
Submit
Review the terms of the Application Policy and submit for application.

The application will be valid for 60 days after the date submitted.
I hereby authorize Central Seal Company -- hereafter referred to as "Central Seal" -- to investigate my past employment, education, criminal background history, credit history, driving record, medical history, worker's compensation history, military service, and other matters as may be necessary in arriving at decision relating to my employment. Further, I release my previous employers, personal references and all other responders to Central Seal inquiries from liabilities of damages on account having furnished information about me in good faith and in accordance with applicable laws.

I understand that current and/or previous employers will be contacted for the purpose of investigating my records. In particular, I authorize Central Seal to seek information concerning my criminal background history, my driving history, my safety performance history, and my participation in and results of employer drug and alcohol testing (including refusals) in accordance with Federal Motor Carrier Safety Regulations (FMCSR). Accordingly, I acknowledge my consent with special regard to government law enforcement agencies, related third party report services, and other persons or organizations holding such information about me to share these records with Central Seal, releasing them from any liability for their contributions. I acknowledge my right: 1)to review information provided by previous employers; 2) to have errors in the information corrected by previous employers and for those previous employers to resend the corrected information to the prospective employer; and 3) to have a rebuttal statement attached to the alleged erroneous information if the previous employer(s) and I cannot agree on the accuracy of the information. Should I become a Central Seal employee, I acknowledge the requirement of periodic inquiries into my FMCSR related records during and after my period of employment. Accordingly, I extend my consent and release of liability for damages regarding persons or organizations involved in sharing my FMCSR records during and beyond my period of employment. A FAX or a scanned or photographic copy of this authorization shall be as valid as the original.

I acknowledge that Central Seal seeks to hire, without discrimination, only lawful workers. I hereby confirm my eligibility for legal employment within the U.S., and I understand that my identification and my eligibility for legal employment within the U.S. will be verified by the U.S. Department of Homeland Security and the Social Security Administration.

I understand that I am entitled to a statement of my rights under the Fair Credit Reporting Act. I understand that information regarding sex, race and date of birth is requested in compliance with federal and state laws and will not be used to discriminate against me.

I certify the accuracy and completeness of all information I provide in this application and during my subsequent interview(s). I understand that providing false or misleading information may result in rejection of my application or a termination of my employment and associated benefits in the event that I am employed with Central Seal. Finally, I understand that I am required to abide by all of Central Seal' rules and regulations. THIS APPLICATION IS VALID ONLY FOR 60 DAYS FROM THE SUBMITTED.
I have read and agree to the Application Policy*
- I agree
Signature*
Name Date
Email
This field is for validation purposes and should be left unchanged.

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