Date of Application * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 Position(s) Applied for * Name Last * First * Middle * Social Security No. * Phone Number * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Have you worked for Diamond Before? * Yes No Are you employed now? * Yes No Date available for work? * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201920202021 Legal to work in the United States? * Yes No Referred by Click to Expand LIST YOUR ADDRESS OF RESIDENCY FOR THE PAST 3 YEARS Current Address * City * State * Zip * How Long? * Previous Address City State Zip How Long? Previous Address City State Zip How Long? Previous Address City State Zip How Long? Is there any reason you might be unable to perform the functions of the job for which you have applied? * Yes No If yes Please Explain Click to Expand DRIVERS LICENSES State * License No. * Type(Class) * Expiration Date * State License No. Type(Class) Expiration Date State License No. Type(Class) Expiration Date A: Have you ever been denied a license, permit or privilege to operate a motor vehicle? * Yes No B: Has any license, permit or privilege ever been suspended or revoked? * Yes No IF EITHER A. OR B. WAS ANSWERED YES, EXPLAIN BELOW All Applicants must provide Complete Information for all employers during the past 10 Years. Applications without complete employment history may not be considered Click to Expand Employment HIstoryEmployer Name * Date From and To * Address * City * State * Zip * Contact Person * Position Held * Wages * Reason for Leaving * Employer Name Date From and To Address City State Zip Contact Person Position Held Reason for Leaving Employer Name Date From and To Address City State Zip Contact Person Position Held Reason for Leaving Employer Name Date From and To Address City State Zip Contact Person Position Held Reason for Leaving Traffic(Tickets) and/or criminal convictions(felonys) for the past 3 years- Do no include parking violations. If none, write None. Click to Expand Ticket Record Location Date Charge Penalty Location Date Charge Penalty Location Date Charge Penalty Location Date Charge Penalty Accident Record for the Past 3 Years - If None, Write None. Click to Expand Accident Record Date Nature of Accident Fatalities Injuries Date Nature of Accident Fatalities Injuries Date Nature of Accident Fatalities Injuries Date Nature of Accident Fatalities Injuries Driving Experience - If none, write None. Click to Expand Driving ExperienceStraight Truck From To Approximate Number of Miles Tractor & Semi-Trailer From To Approximate Number of Miles Hauling Heavy Equipment From To Approximate Number of Miles Belly Dump Equipment From To Approximate Number of Miles List states you have operated in for the last five years Education Select the highest grade completed 1 2 3 4 5 6 7 8 High School 9 10 11 12 College 1 2 3 4 Show any courses, training or experience that will help you at the position applied for Last school attended Name City TO BE READ BY THE APPLICANT By submitting this form certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. I authorize you to make such investigations and inquire of my personal, employment, criminal history, medical history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers and other persons from all liability in responding to inquires and releasing information in connection to 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 Diamond Service Company
