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Pre-Employment Application
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.
Name*
First Last
Phone*
Email*
Position Applied For*
Current Address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
How long have you lived at your current address?*
Previous Address
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
How long have you lived at your previous address?*
Do you have a legal right to work in the United States?*
- Yes
- No
Date of Birth*
Date Format: MM slash DD slash YYYY

Required for Commercial Drivers
Can you provide proof of age?*
- Yes
- No
Have you worked for this company before?*
- Yes
- No
Where?*
From Date*
Date Format: MM slash DD slash YYYY
To Date*
Date Format: MM slash DD slash YYYY
Rate of Pay*
Position*
Reason for leaving?*
Are you currently employed?*
- Yes
- No
How long since your last employment?*
Explanation*
Who referred you?
Rate of pay expected*
Are you able to perform the essential functions for the job of which you have applied, with or without, reasonable accomodations?*
- Yes
- No
Explanation*
Employment History
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding three years. List the complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional seven years' information on those employers for who the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent.)
Employer Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
From Date*
Date Format: MM slash DD slash YYYY
To Date*
Date Format: MM slash DD slash YYYY
Wage*
Phone*
Reason for leaving?*
Employer
Employer Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From Date
Date Format: MM slash DD slash YYYY
To Date
Date Format: MM slash DD slash YYYY
Wage
Phone
Reason for leaving?
Employer
Employer Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From Date
Date Format: MM slash DD slash YYYY
To Date
Date Format: MM slash DD slash YYYY
Wage
Phone
Reason for leaving?
Employer
Employer Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From Date
Date Format: MM slash DD slash YYYY
To Date
Date Format: MM slash DD slash YYYY
Wage
Phone
Reason for leaving?
Accident Report for the past 3 years or more
Write in the box below if more space is needed. If none, write NA. Includes all vehicles with a GVWR or 26,001 lbs or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placards.
Date
Date Format: MM slash DD slash YYYY
Nature
Describe
Date
Date Format: MM slash DD slash YYYY
Nature
Fatalities?
- Yes
- No
Injuries?
- Yes
- No
Describe
Traffice Convictions and Forfeitures for the past 3 Years
Other than parking violations.
Location
Date
Date Format: MM slash DD slash YYYY
Charge
Penalty
Penalty
Location
Date
Date Format: MM slash DD slash YYYY
Charge
Penalty
Location
Date
Date Format: MM slash DD slash YYYY
Charge
Penalty
Use this box to describe any additional convictions.
Do you have a history of a misdemeanor conviction?*
- Yes
- No
Do you have a history of a felony conviction?*
- Yes
- No
Explanation*
Note: No applicant will be denied employment solely on the grounds of a misdemeanor or felony conviction.
Education
Do you have either a high school diploma or a G.E.D?*
- Yes
- No
Last School Attended*
City*
Experience and Qualifications – Driver Licenses
State*
License Number
Type*
Expiration Date*
Date Format: MM slash DD slash YYYY
State
License Number
Type
Expiration Date
Date Format: MM slash DD slash YYYY
State
License Number
Type
Expiration Date
Date Format: MM slash DD slash YYYY
Have you ever been denied a license, permit, or priviledge to operate a motor vehicle?*
- Yes
- No
Has any license, permit or privilege ever been suspended or revoked?*
- Yes
- No
Explanation*
Driving Experience
Straight Truck
Type of Equipment
Van, Tank, Flat, etc.
Date from
Date Format: MM slash DD slash YYYY
Date to
Date Format: MM slash DD slash YYYY
Approx Number of Miles Total
Tractor and Semi-trailer
Type of Equipment
Van, Tank, Flat, etc.
Date from
Date Format: MM slash DD slash YYYY
Date to
Date Format: MM slash DD slash YYYY
Approx Numner of Miles Total
Tractor – Two Trailers
Type of Equipment
Van, Tank, Flat, etc.
Date from
Date Format: MM slash DD slash YYYY
Date to
Date Format: MM slash DD slash YYYY
Approx Numner of Miles Total
Motorcoach/School Bus
Type of Equipment
Van, Tank, Flat, etc.
Date from
Date Format: MM slash DD slash YYYY
Date to
Date Format: MM slash DD slash YYYY
Approx Numner of Miles Total
Other
Type of Equipment
Van, Tank, Flat, etc.
Date from
Date Format: MM slash DD slash YYYY
Date to
Date Format: MM slash DD slash YYYY
Approx Numner of Miles Total
States operated in for the last five years?
Courses or training completed?
List those that help you as a driver.
Have you won any special driving awards?
- Yes
- No
Describe the award and from whom you won them.
Experience and Qualifications – Other
Show any trucking, transportation or other experience that may help in your work for this company.
List any courses or training not shown elsewhere in this application.
List special equipment or technical materials you can work with.
Do not list those that are listed elsewhere in this application.
Addtional Information
Use this box to include any additional information that you think would help us in the decision to offer you employment.
TO BE ACKNOWLEDGED BY APPLICANT
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.
I authorize you to make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with 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 the company.
Submitting this application 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. 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 the Company.
Name*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY
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1887 Route 764 / Duncansville, PA 16635
P.O. Box 836 / Duncansville, PA 16635
(814) 943-5563 / (800) 446-5377

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Truck Driver Application

Imler’s Poultry wholesale customers can now pay their bills online!

Pre-Employment Application

Current Address

Previous Address

Employment History

Employer

Employer

Employer

Accident Report for the past 3 years or more

Traffice Convictions and Forfeitures for the past 3 Years

Education

Experience and Qualifications – Driver Licenses

Driving Experience

Straight Truck

Tractor and Semi-trailer

Tractor – Two Trailers

Motorcoach/School Bus

Other

Experience and Qualifications – Other

TO BE ACKNOWLEDGED BY APPLICANT

Contact Jeff Katelan

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