ANADARKO DOZER & TRUCKING L.L.C.

1121 S. MAIN ELK CITY, OK. 73644

DATE: ______Hired / Interviewed by: ______

NAME: ______

Home phone:______Cell:______

ADDRESS: ______

(Street) (City) (State) (Zip)

SOCIAL SEC. # ______POSITION APPLYING FOR ______

REFERRED BY ______

PREVIOUS

ADDRESS: 1. ______

(Street) (City) (State) (Zip)

2. ______

(Street) (City) (State) (Zip)

Emergency Contact:

1. Name______Phone # ______

2. Name______Phone # ______

Are you able to, with or without a reasonable accommodation, lift 50 Lbs. or more, repetitively? ______

Have you ever worked for this company before? ______if yes, Where? ______

A. Have your ever been denied a license, permit or privilege to operate a motor vehicle? Yes____ No____

B. Has any license, permit or privileges ever been suspended or revoked? Yes ______No______

C. Are you legally able to work within the United States?

If the answer to either A or B is yes, Explain: ______

______

EXPERIENCE AND QUALIFICATIONS

Driver
licenses / STATE / LICENSE NO. / TYPE / EXPARATION DATE

DRIVING EXPERIENCE

Class of Equipment / Type of Equip.
Van, tank, flat, etc. / From date / To date / Total years, months, etc.
Straight truck
Tractor & semi-trailer
Tractor & two trailers
Other
Dozer
Motor grader
Scraper
Backhoe
Trackhoe
Mechanic

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (attach sheet if more space is needed)

Dates / Nature of accident / Fatalities / Injuries
Last accident
Next previous
Next previous

Traffic convictions and forfeitures for the past 3 years

Location / Date / Charge / Penalty

Note: DOT Requires that Employment for at least 3 years and /or Commercial Driving Experience for the past 10 years be shown.

Previous Employer:

1.  Name ______Contact______

Address ______Phone______

Position ______From ______To ______

Reason for leaving ______

Previous Employer:

2.  Name ______Contact______

Address ______Phone______

Position ______From ______To ______

Reason for leaving ______

Previous Employer:

3.  Name ______Contact______

Address ______Phone______

Position ______From ______To ______

Reason for leaving ______

Previous Employer:

4.  Name______Contact______

Address______Phone______

Position______From______To______

Reason for leaving______

Previous Employer:

5.  Name______Contact______

Address______Phone______

Position______From______To______

Reason for leaving______

______

References: (non related)

1. Name ______Address ______Phone______

2. Name ______Address ______Phone ______

3. Name ______Address ______Phone ______

This certifies that the application was completed by me and that all entries on it and information in it are true and to the best of my knowledge.

In connection with Anadarko Dozer and Trucking, LLC considering me for employment, continued employment promotion or reassignment, I authorize AD&T, LLC and/or its agent to obtain a consumer report which may include information on my character, general reputation, personal characteristics, and mode of living from public record sources or through personal interviews with previous employers or associates. Public record check may include but not limited to a criminal or felony background check and sex offender’s registry check. I understand that a consumer reporting agency investigation may include obtaining a motor vehicle license and understand that we will conform to the Driver Privacy Protection Act. The applicant is required for the motor vehicle to provide a consent form and a photo I.D. before obtaining the record. Our company will retain the consent form and the results for a period of 5 years.

I authorize, without reservation, any person or entity contacted by Anadarko Dozer & Trucking, LLC or its agent to furnish the above-stated information and I release any such person or entity from any and all liability for furnishing such information. I further release Anadarko Dozer & Trucking, LLC., its affiliate companies, their officers, employees and agents, and specifically, Anadarko Dozer & Trucking, LLC, their affiliated companies, their officers, employees and agents from any liability and responsibility arising from the preparation of said report. I understand that false or misleading statements or information made on this authorization, or made during the employment process, will disqualify me from consideration for employment or result in immediate discharge if employed.

You have the right, upon written request, to receive a written description of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act.

“I swear and affirm that everything I this application is true and correct. I understand that Anadarko Dozer & Trucking, LLC, reserves the right to refuse to hire me or to take disciplinary action up to and including discharge if it discovers that I have falsified any of the information in this application. Further, I consent to the background checks described in this application.”

I HEREBY ACKNOWLEDGE RECEIPT:

______

Print Name Date

______

Signature

______

Witness Date

NOTE: a motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations