Jr. Davis Construction Application for Employment

Applicant Information
First Name: Last Name:
Address:
City: Phone:
State: Email:
Zip: Date of Birth:
Date Available: Desired Salary:
Position Applied for:    Concrete Laborer
Add additional positions?
Are you 18 years or older?   Yes   No 
Are you a citizen of the United States?   Yes   No  If No, Are you authorized to work in the U.S.?   Yes   No 
Have you ever worked for this company before?   Yes   No  If Yes, When?
Have you ever been convicted of a felony?   Yes   No  Will not necessarily exclude you from consideration.
If Yes, Explain:
Previous Address (Past Three Years)
AddressCityStateZipHow Long
Qualifications - Driver Licenses
State License No. Type Expiration Date
Driving Experience
Class of EquipmentType of Equipment
(Van, Tank, Flat, Etc.)
From DateTo Date
Straight Truck
Tractor and Semi-Trailer
Tractor - Two Trailers
Other
Accident Record For The Past 7 Years Or More (attach sheet if more space is needed)
DatesNature of Accident
(Head-On, Rear-End, Upset, Etc)
FatalitiesInjuries
Traffic Convictions And Forfeitures For The Past 7 Years (other than parking violations)
LocationDateChargePenalty
Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No
If yes, explain.
Has any license, permit or privilege ever been revoked? Yes No
If yes, explain.
Education
High School: Did you graduate?Yes No
College: From: To:
Did you graduate?Yes No Degree:
Other: From: To:
Did you graduate?Yes No Degree:
References
Please list three professional references.
Full Name: Relationship
Company: Phone:
Address:
Full Name: Relationship
Company: Phone:
Address:
Full Name: Relationship
Company: Phone:
Address:
Previous Employment
Note: Dot Requires That Employment for at Least 3 Years and/or Commercial Driving Experience for the Past 10 Years Be Shown
Company: Phone:
Address: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
Reason for leaving: From: To:
May we contact your previous Supervisor for a reference?  Yes No
Was your job designated as a saftey-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of
49 CFR part 40?  Yes No
Company: Phone:
Address: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
Reason for leaving: From: To:
May we contact your previous Supervisor for a reference?  Yes No
Was your job designated as a saftey-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of
49 CFR part 40?  Yes No
Company: Phone:
Address: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
Reason for leaving: From: To:
May we contact your previous Supervisor for a reference?  Yes No
Was your job designated as a saftey-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of
49 CFR part 40?  Yes No
Company: Phone:
Address: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
Reason for leaving: From: To:
May we contact your previous Supervisor for a reference?  Yes No
Was your job designated as a saftey-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of
49 CFR part 40?  Yes No
Company: Phone:
Address: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
Reason for leaving: From: To:
May we contact your previous Supervisor for a reference?  Yes No
Was your job designated as a saftey-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of
49 CFR part 40?  Yes No
Military Service
Branch: From: To:
Rank at discharge: Type of discharge:
If other then honorable, explain:
Additional
How did you hear about us?
If other, specify?
Are you bilingual? If so, what languages do you fluently speak?
Additional skills:
Attach Resume
You may attach your resume or other relevent documents here. (PDF/Word/JPG) only.
Add another document?
Disclaimer
I certify that my answers are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this
application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information
concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from any
damage that may result from utilization of such information.

I also understand an agree that no representative of the company has any authority to enter into any agreement for employment for any
specified period of time, or to make any agreement contrary to the foregoing , unless it is in writing and signed by an authorized company representative.
Print Name: Date: 06-19-18
By submitting this online application you agree to the disclaimer above.
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.
Previous Empolyment and DOT Safety Sensitive Data Verification
Section I. To be completed by the new employer, signed by the applicant, and transmitted to the previous employer:
Applicant Name: SSN:

I hereby authorize release of previous work information, in accordance with Section 391.23 of the Federal Motor Carrier Safety Regulations, as well as release of information from my Department of Transportation regulated drug and alcohol testing records, in accordance with DOT Regulation 49 CFR Part 40, Section 40.25, from my previous employer listed in Section I-B, to the employer listed in Section I-A. I understand that information to be released in Section II-A (2) by my previous employer is limited to the following DOT-regulated testing items:

  1. Alcohol tests with a result of 0.04 or higher
  2. Verified positive drug tests;
  3. Refusals to be tested;
  4. Other violations of DOT agency drug and alcohol testing regulations;
  5. Information obtained from previous employers of a drug and alcohol rule violation;
  6. Documentation, if any, of completion of the return-to-duty process following a rule violation.
Applicant Signature: Date: 06-19-18
I-A.I-B.
New Employer:Jr. Davis Construction Company, Inc. / S&L Materials, Inc. Previous Employer: ________________________________
Address:210 S. Hoagland Blvd. Address: ________________________________
Kissimmee, FL 34741 ________________________________
Phone #:407-870-0066Phone #: ________________________________
Fax #:407-870-9377Fax #: ________________________________
D.E.R.:Jennifer Montgomery/Lydia Pena-MatthewsD.E.R. (if known): ________________________________
Section II. To be completed by previous employer and transmitted by mail or fax to the new employer:
II-A (1).
1. Individual named above worked for your company from __________________________ to _________________________
2. Driver: _____Yes _____No
3. Type of vehicle the named individual drove for your company.
________Dump Truck ________Tractor Trailer ________Flat Bed ________Tanker ________Other _________________
4. Was the above named individual a safe/efficient driver? _____Yes _____No
5. Reason for leaving your company: ______________________________________________________________________
6. Past 3 year driving record preceding the date of application to you (if available): __________________________________
7. Any accidents while employed with your company? If yes, please explain in additional comments below: _____Yes _____No
Additional Comments: ________________________________________________________________________________
II-A (2). Did this person hold a safety sensitive position which was subject to D.O.T. testing regulations? _____Yes _____No
If you answered “yesâ€, please answer the questions below. If you answered “noâ€, skip to section II-B.
In the three years prior to the date of the employee’s signature (in Section I), for DOT-regulated testing –
1. Did the employee have alcohol tests with a result of 0.04 or higher?Yes _____ No _____
2. Did the employee have verified positive drug tests?Yes _____ No _____
3. Did the employee refuse to be tested?Yes _____ No _____
4. Did the employee have other violations of DOT agency drug and alcohol testing regulations?Yes _____ No _____
5. Did a previous employer report a drug and alcohol rule violation to you?Yes _____ No _____
6. If you answered “yes†to any of the above items, did the employee complete the return-to-duty process?N/A _____Yes _____ No _____
NOTE: If you answered “yes†to item 5, you must provide the previous employer’s report. If you answered “yes†to item 6, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record).
II-B.
Name of person providing information in Sections II-A (1) & II-A (2): _____________________________________________
Title: _____________________________________________
Phone #: __________________________________________Date: __________________________________
AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION

Under the Fair Credit Reporting Act (“FCRAâ€), 15 U.S.C. SS 1681 et seq., the regulations applicable to the federal Department of Transportation’s Federal Motor Carriers Safety Administration, including 49 CFR SS 40.329, the Americans with Disabilities Act and all other applicable federal, state, and local laws, I hereby authorize and permit Jr. Davis Construction Company Inc. / S&L Materials, Inc. to obtain information, where permitted, pertaining to my employment records, driving history records, driving performance and safety history, criminal history, credit history, civil records, workers’ compensation (post-offer only), alcohol and drug testing, verification of my academic and/or professional credentials, and information and/or copies of documents from any military service records.

understand that an “investigative consumer report†may result that could include information as to my character, general reputation, personal characteristics, and mode of living that may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information. I specifically authorize the release of information by my former employers for the purpose of satisfying driver qualification regulations.

DOT Drivers. I understand that Title 49 of the Federal Code of Regulations, SS 391.23, requires that my prospective employer and/or its agent(s) may contact all former employers of a driver within the last three years under the regulation of the Department of Transportation. Information such as dates of employment, position, accident history, as well as information pertaining to my drug and alcohol testing history, may be requested from each employer in accordance with Section 391.23 and 49 CFR 40.25.

By signing below, I consent to and authorize the gathering of this information by my prospective employer and those whom my prospective employer has engaged to request and obtain this information, including from former employers and/or from or through iiX. I hereby release and hold harmless any person, firm, or entity, including iiX, that discloses matters in accordance with this authorization from liability that might otherwise result from the request for use of and/or disclosure of any or all of the information discussed above. This information may be obtained in whole or part by iiX or its agents.

I consent to and authorize processing of my information in a foreign country by persons providing services to my prospective employer and understand that this information may be accessible to law enforcement and national security authorities of that jurisdiction.

I understand and acknowledge that this release of information may assist my prospective employer to make a determination regarding my suitability as an employee. I further understand that under the FCRA, I may request a copy of any consumer report from the consumer reporting agency that compiled the report, after I have provided proper identification. I agree that a copy of this authorization has the same effect as an original. Where permitted, this authorization shall remain in effect over the course of my employment and reports may be ordered periodically during the course of my employment.

Print Name: Date of Birth:
Current Address:
Drivers License #: State Issued:
Signature: Date:06-19-18
Summary of Rights under FCRA (pdf)