Application to Willmar Bus Service

Name

Social Security #

Current Address

If at the above residence less than three years, list below all residences for the past three years.

Phone

Position applying for

Temp Part Time Full Time

Who referred you?

Have you worked for Willmar Bus before?

Yes
No
When?
Rate of Pay Position

Reason for Leaving

Names of any relatives employed by Willmar Bus

Are you currently employed?

If not how long since your last employment?

Education

Highest grade completed

Last School Attended

General

Have you ever been bonded?

Yes Name of bonding company

Have you ever worked for Willmar bus under another name?

Yes If so under what name?

Driver Experience and Qualification

Drivers Licenses held in the last 3 years

State License No. Class

Endorsements Expiration Date

Additional

Have you eveer been denied a license, permit or previlege to operate a motor vehicle?

Yes
No

Has any license, permit or previlege ever been suspended or revboked?

Yes
No

Driving Experience

Accident Record for the past 3 years

Dates, Nature of accident, Fatalities?, Injuries?, Hazardous Material Spill

Traffic Convictions and Forfeitures for the past 3 years (not parking violations)

Location, Date, Charge, Penalty

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code. Applicants must include the names of DOT-regulated employers under whose authority they operated as a contractor or leased driver.

Applicants to drive a commercial motor vehicle that requires a CDL in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle. 7 years information on those employers for whom the applicant operated such vehicle.

Employer 1

Name

Address

City State Zipcode

Contact person Phone Number

Were you subject to the FMCSRs while employed? Yes No

Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? Yes No

Date

Dates employed

Position Held

Salary/Wage

Reason for Leaving

Employer 2

Name

Address

City State Zipcode

Contact person Phone Number

Were you subject to the FMCSRs wile employed? Yes No

Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? Yes No

Date

Dates employed

Position Held

Salary/Wage

Reason for Leaving

Employer 3

Name

Address

City State Zipcode

Contact person Phone Number

Were you subject to the FMCSRs wile employed? Yes No

Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? Yes No

Date

Dates employed

Position Held

Salary/Wage

Reason for Leaving

Other Experience and Qualifications

List courses and training in maintenance work

Read and Sign

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.

Name Agree