Employment Application

Contact Info

Please Answer All Questions. Resumes Are Not a Substitute for a Completed Application

We are an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.

Position

Driver applicants will not need to complete Step 3

Non-Driver applicants will not need to complete Step 4

CDL Driver

Non-Driver

Position Applied For

Name

Telephone Number

Alternate or Cell Telephone Number

Present Address

City

State

Zip

How long have you lived there?

Previous Address

City

State

Zip

How long have you lived there?

Date on which you can start work if hired

Desired Salary/Hourly Rate

Type of employment desired?

Full-Time

Part-Time

(Specify Hours)

Are you willing to work overtime? Yes No

If under the age of 18, Can you produce the necessary work certificate at time of employment? Yes No

Have you previously applied for employment with this Company? Yes No

If yes, when and where did you apply?

Have you ever been employed by this Company? Yes No

If Yes, provide dates of employment, location, and reason for separation from employment.

INSTRUCTIONS FOR ANSWERING THE NEXT TWO QUESTIONS

1. All applicants: Do not include convictions that were sealed; eradicated, erased; annulled by a court, or expunged, or convictions that resulted in referral to a diversion program.
2. Arizona, Colorado, District of Columbia, Illinois, Kansas, Minnesota, Missouri, Montana, Nevada, Rhode Island, South Carolina and Utah applicants: Do not respond to the second question regarding arrests.
3. California applicants: Do not include misdemeanor marijuana-related convictions that are more than two (2) years old or misdemeanor convictions for which probation was successfully completed or otherwise discharged and the case was judicially dismissed.
4. Connecticut applicants: You are not required to disclose the existence of any arrest, criminal charge, or conviction, the records of which have been erased. Criminal records subject to erasure are records pertaining to a finding of delinquency or the fact that a chl1d was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or knolled (not prosecuted), a criminal charge for which the person was found not guilty, or a conviction for which the offender received An absolute pardon. Any person whose criminal records have been erased is deemed to have never been arrested within the meaning of The law as it applies to the particular proceedings that have been erased, and may so swear under oath.
5. District of Columbia and Washington applicants: Limit any response to the past ten (10) years.
6. Hawaii and Massachusetts applicants; Do not answer the following two questions.
7. Indiana applicants: Regarding arrests limit your response to pending charges for felonies and class A misdemeanors that are less than One (1)
8. Michigan applicants: Regarding arrests, limit your response to felony arrests awaiting conviction or dismissal.
9. New York applicants: All pending arrests or criminal accusations must be disclosed. You are not required to disclose arrests or criminal accusations at resulted in criminal actions or proceeding which were terminated in your favor. Do not disclose criminal actions or proceedings that were sealed or classified as youthful offender adjudications. An ex-offender who is denied employment may, upon written request, receive a statement of the reason(s) for denial within thirty (30) days of the applicant's request for such information.
10. North Dakota and Oregon applicants: Regarding arrests, limit your response to pending charges that are less than one (1) year old.
11. Utah applicants; Limit any response to felony convictions only. Do not respond to the second question regarding arrests.

Have you ever plead guilty or no contest to, or been convicted of any criminal offense other than the applicable exceptions listed above? Yes No

Have you ever been arrested for any matters for which you currently are out on bail or on your own recognizance pending? Yes No

Criminal OFFENSES ONLY: If you answered Yes, to either of the above two questions, please provide the date(s) and explain in accordance with the above instructions so that individual circumstances can be considered.

Criminal convictions or arrests will not automatically disqualify an applicant from a particular job. The Company will consider the nature of the crime, its seriousness, the substantial relation to the position's functions and qualifications, the number of occurrences, the applicant's age at the time of the crime, the time elapsed since the crime, the applicant's entire work and educational history, employment references and recommendations, and the business necessity of any exclusion when required by law.

Have you ever initiated an act of violence in the workplace? Yes No

If yes, please provide the date(s) and explain so that individual circumstances can be considered. (A 'Yes' answer will not necessarily disqualify you from employment)

List all special technical skills that you feel qualify you for the job for which you are applying (For example, computer programming/language, software, equipment operation, special tools or machines, etc.)

High School

School Name and Location

Course of Study

Did You Graduate?

Yes No

Years Completed

College

School Name and Location

Course of Study

Did You Graduate?

Yes No

Years Completed

Degree/Major

Bus/Tech/Trade or Post College

School Name and Location

Course of Study

Did You Graduate?

Yes No

Years Completed

Degree/Major

Honors Received

If applicable, list below any other names by which you have been known which may be necessary to allow us to confirm your work and educational record.For example, change of name, use of an assumed name, nickname, etc.

REFERENCES

Please list the names of additional work-related references we may contact. Individuals with no prior work experience may list school or volunteer-related references.

Reference 1

Name

Position

Company

Telephone

Work Relationship (i.e Supervisor, Co-worker)

Reference 2

Name

Position

Company

Telephone

Work Relationship (i.e Supervisor, Co-worker)

Please list the names of personal references (not previous employers or relatives) who know you well that we may contact.

Personal Reference 1

Name

Occupation

Telephone

Number of Years Known

Address

Personal Reference 2

Name

Occupation

Telephone

Number of Years Known

Address

Shift Policy

AGREEMENT TO ACCEPT NIGHT AND WEEKEND WORK

Applicant:
A second shift is required to meet our present needs. All new employees are hired with the understanding that they are able and willing to work nights and weekends.
Please answer the following:

1) Do you have any physical condition that would prevent You from working nights? Yes No

2) Do you know of any personal reasons that would Interfere with your working nights and weekends ? Yes No

3) Are you willing to work nights and weekends? Yes No

I understand that any employment is conditioned upon my acceptance of a night and weekend assignment.

Signed

Dated

In the presence of

Non-Driver Application

THIS PAGE TO BE FILLED OUT BY NON-DRIVER APPLICANTS ONLY

Please list the names of your present and/or previous employers in chronological order with present or last employer list first. Account for all periods of time including any period of unemployment. If self-employed, supply firm name and business references. You may include any verifiable work performed on a volunteer basis, internships, or military service. Your failure to completely respond to each inquiry my disqualify you for consideration from employment.

Employer

Address

Telephone

Type of Business

Job Title

Date Employed From

Date Employed To

Duties

Supervisor's Name

May we contact? Yes No

If No, Why not?

Wages Start

Wages Final

What will this employer say was the reason for your employment terminated?

How much notice did you give when resigning? If none, explain

Reason for Leaving

Please explain fully all gaps in your employment history in excess of one month.

Have you ever been terminated or asked to resign from any job? Yes No

If yes, how many times?

Has your employment ever been terminated by mutual agreement? Yes No

If yes, how many times?

Have you ever been given the choice to resign rather than be terminated? Yes No

If yes, how many times?

If you answered YES to any of the above questions, please explain the circumstances of EACH occasion.

CDL Driver Application

APPLICATION FOR EMPLOYMENT- CDL DRIVERS ONLY

We are an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed member service, race, religion, sex, national origin, age, genetic information, or any other category protected by applicable federal, state or local laws. Terpening Trucking Co., Inc. is at at-will employer as allowed by applicable state law. This means regardless of any provision in this application, if hired, the Company or the employee may terminate the employment relationship at any time, for any reason, without cause or notice. As Terpening Trucking is a DOT-Regulated Carrier, all applicants must be qualified under all applicable DOT regulations.

Name

DOB

Have you previously applied to Terpening Trucking? Yes No

If yes, when?

Have you previously worked for Terpening Trucking? Yes No

If yes, when?

CDL INFORMATION

License Number

State

Endorsements

Issue date

Expiration Date (License)

Expiration Date (HM end.)

Do you have an enhanced license? Yes No

Other – Credential Information

TWIC Card Expiration Date

FAST Card Expiration Date

Passport (country of issue)

Passport Expiration Date

Others (List)

Pre-employment drug test notification

Per FMCSA regulation, all CDL driver applicants must be drug tested, and a 5-panel negative result received by the employer, before being assigned to a safety sensitive position. Your signature below acknowledges that you have been notified of this requirement, and will be sent for testing.

Signature

Date

Employment History

List in reverse order your employment history for the past 10 years. If work history is not that long, list back to the first job and annotate in the margins that this was your first position.

Employer Name

Contact Person

Address

Phone

Position Held

DOT Regulated? Yes No

DOT Safety Sensitive position which required drug and alcohol testing? Yes No

Date of Employment Start

Date of Employment End

Reason for leaving

Driving Experience

Type of Equipment

Dates Operated Start

Dates Operated End

Miles Run

What States have you operated in?

List Traffic Convictions for the past 3 years (exclude parking tickets)

Location

Date

Charge

Penalty

List any accidents that you have been involved in within the past 3 years

Location

Date

Type

<---->

Injuries/Fatalities

Hiring Policy- Driver Applicants

Applicant must:
1. Be at least 23 years old
2. Have at least one full year of verifiable experience driving tractor/trailer
3. Hold a valid Commercial Driver’s License (CDL), class A, with X (Tank & Hazmat) endorsement
4. Not be currently disqualified, for any reason, from driving a Commercial Motor Vehicle (CMV)
5. Have a currently valid DOT physical
6. Account completely and accurately for all employment for the preceding 10 years.
7. Be qualified under all FMCSR standards for CMV operators
8. Not have any past convictions for DWI, DWAI, or DUI

Pre-hire procedure:
1. Application filled out on Terpening premises
2. Interview with Terpening management
3. Road test by safety coordinator or his designated substitute
4. MVR check, violation certification, and past employment check
5. Review of long form of DOT physical (provided by applicant)
6. Drug Screen

Job Description:

The applicant must be qualified to drive a tractor/tank semi-trailer combination, hauling placarded hazardous materials, in interstate commerce. Additional responsibilities and duties shall include, at a minimum:
- All DOT-mandated procedures and paperwork;
  Loading and unloading procedures for tank trailers;
  Terpening paperwork; Adherence to work schedule as set by Terpening dispatch

A copy pf the complete Driver’s Job Description and Company Policy will be provided at the applicant’s request.

“I have read the above. I understand that any falsification or omission of information on this application may result in termination of any consideration for employment.”

Date

Signature

Notification of Driver’s Rights

In accordance with Federal Motor Carrier Safety Administration regulation 391.23 (i)(1), we are required to make known to Driver applicants for employment with our company that you have the following rights regarding the investigative information that will be provided to our company pursuant to paragraphs (d) and (e) of this section of the regulation.

1.) You have the right to review information provided by your previous employers
2.) You have the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to our company.
3.) You have the right to have a rebuttal statement attached to the alleged erroneous information if the previous employer and the driver cannot agree on the accuracy of the information.

“I understand that I have been informed of these rights in accordance to the above listed regulation.”

Date

Signature

To be read and signed by the applicant

This certifies that this application was completed by me, and that all entries on it and information within are true and complete to the best of my knowledge. It is also understood that the company will contact my previous employers and verify the information on this application as required by Federal and State DOT.

Date

Applicant Signature

Applicant Certification

I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver’s license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside.

I understand that the company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state and local law. If the company has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law.

If employed by the Company, I understand and agree that the company, to the extent permitted by federal, state, and local law, may exercise its right, without prior notice or warning, to conduct investigations of property (including, but not limited to, files, lockers, desks, vehicles and computers) and, in certain circumstances, my personal property.

I understand and agree that as a condition of employment and to the extent permitted by federal, state and local law, I may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement, as well as an agreement to arbitrate.

I certify that all the information on this application, my resume, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.

THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELAIONSHIPAT ANY TIME, FOR ANY REASON, WITH OR WITHOU CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER AN AGREEMENT-EXPRESS OR IMPLIED- WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY.

IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCPET THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL.

I authorize the company or its agents to confirm all statements contained in this application and/or resume as it relates to the position I am seeking and to the extent permitted by federal, state or local law. I agree to comply any requisite authorization forms for the background investigation.

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state and local law, any party delivering information to the company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information.

If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this company. I also understand this Company employs only individuals who are legally eligible to work in the United States.

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE.

Applicant Signature

Date

If the applicant is a minor, the foregoing release and consent must be signed by the applicant’s parent or legal guardian. Signature by the applicants parent or legal guardian constitutes acknowledgement by the applicant and the parent or legal guardian that the Company, to the extent permitted by federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate test results to Company personnel who need to know, the applicant, and the applicant’s legal guardian.

Parent/Legal Guardian

Date

Witness

Date

UNDER MARYLAND LAW, AN EMPLOYER MAY NOT RQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DET ECTOR, POLYGRAPH OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100. I have read and understand the above statement.

UNDER MASSACHUSETTS LAW, IT IS UNLAWFUL FOR AN EMPLOYER TO RWQUIRE OR TO ADMINISTER A LIE DETECTOR, POLYGRAPH OR SIMILAR TEST AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. FEDERAL AND/OR STATE LAW MAY PROHIBIT THE USE OF A LIE DETECTOR, POLYGRAPH OR SIMILAR TEST AS WELL. THIS APPLICATION MAY NOT BE APPLICABLE FOR ALL INDUSTRIES.

Applicant Signature

Date