Your Local Disposal Company

Employment

Personal Information

Enter your full legal name as it appears on your Social Security Card.

*First Name:

*Last Name:

*Middle:

*Social Security Number:

*Home Phone:

*Alternate Phone:

*Email Address:

*Street Address:

*City:

*State:

*Zip Code:

________________________________________________________________

Previous Address (3 years of previous residential addresses required)

Previous Address One:

Street Address:

City:

State:

Zip Code:

Date From:

Date To:

Previous Address Two:
Street Address:

City:

State:

Zip Code:

Date From:

Date To:

Previous Address Three:

Street Address:

City:

State:

Zip Code:

Date From:

Date To:

________________________________________________________________

Emergency Contact Information

*Emergency Contact Name:

*Emergency Phone Number:

*Relationship:

________________________________________________________________

Additional Information:

*Work Authorization:

*Desired Start Date:

*Position Desired:

*Employment Status Desired?
Full TimePart Time

*Availability (You may make multiple selections):
WeekdaysWeekendsEveningsNightsAny/All

Have You Ever Worked for Hometown Disposal Before?
YesNo

If yes, what was your reason for leaving?

Do you have any relatives currently employed with Hometown Disposal?
YesNo

If yes, what are their names?

Are you able to perform the essential functions of the job for which you are applying?
YesNo

Are you bound by any active restrictive covenant, non-compete, non-solicitation or non-disclosure/confidentiality agreement with your current or former employer?
YesNo

If yes, explain agreement:

As an employee, have you ever been asked to resign or been discharged?
YesNo

If yes, please explain:

Can you read and speak the English language sufficiently to converse with the general pubic, to understand highway traffic signals in the English language, to respond to official inquiries, and to make entries on reports and records?
YesNo

________________________________________________________________

Drug Testing and Criminal History.

Have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer in which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the previous three years?
YesNo

Have you ever been convicted of a crime other than a minor traffic violation?
YesNo

*If yes, please list each and provide date, description of crime(s), and location/state in the field below.

The existence of a criminal record will not necessarily disqualify you from employment consideration. Failure to disclose such information may result in disqualification of your application or termination of employment.

________________________________________________________________

Employment History: Complete 10 years of employment history. Include periods of unemployment.

*Company Name:

*Street Address:

*City:

*State:

*Phone:

*Title:

*Date From:

*Date To:

*Reason for Leaving:

*Starting Rate of Pay:

*Final Rate of Pay:

*Direct Supervisor:

*Supervisor Title:

*Is it okay to contact this employer?:
YesNo

*Responsibilities and Duties:

*While Employed with this company, did you drive a CMV with a GVWR greater than 26,001 pounds?
YesNo

*Please list the types of equipment you are currently capable of driving:

*If Other, Please Specify:

While you were employed with this company, were you subject to Federal Motor Carrier Safety Regulations, and was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?
YesNo

While employed with this company were you required to participate in their pre-employment, random, reasonable suspicion or post accident DOT drug/alcohol program?
YesNo
________________________________________________________________

Education: Include High School and all Higher Education Institutions.

*High School Name:

*City:

*State:

*Do you have a high school diploma or GED (general education degree):
YesNo

*Year Received:

College or University Name:

City:

State:

Major:

Number of Years Completed:
0-11-22-33-44+

Did you receive a degree?
YesNo

Year Received:

________________________________________________________________

Driving Information:

*Name on License/Certification:

*Drivers License Classification:

*Issuing State:

*License Number:

*Expiration Date:

Has your license or certification ever been revoked or suspended? If yes, please explain below and include dates.
YesNo

Were you involved in any accidents/incidents with any vehicle in the last 3 years?
YesNo

Please provide details in the box below regarding any and all accidents including date and nature of each accident and any personal injuries and/or fatalities.

Have you had any traffic tickets in the last 3 years? If yes please explain below and include dates.
YesNo

________________________________________________________________

DOT DRIVERS’ LEGAL RIGHTS TO INVESTIGATE EMPLOYMENT HISTORY GATHERED BY THIS COMPANY FROM PREVIOUS EMPLOYERS

Effective October 29, 2004, DOT requires this company to notify you, before you submit your job application to us, of your rights regarding your previous employment information that we are required to obtain while conducting your background checks. This information covers any accident, as of April 29,2003, that you may have been involved in. Accident information will cover a three year period prior to the date of your application. In addition, information on your personal compliance to DOT Federal Drug and Alcohol regulations for the past three years will be shared with this company.

You have the right to review this information provided by your previous employers. If you wish to review this information, you must submit a written request to the safety department within thirty days after being hired. The company must respond to your request within five business days once we obtain the information. You must arrange to pick up the requested information within thirty days after the company notified you that the information is available. The company does not do an employee history investigation until after a driver is hired.

You have the right to have errors in the information corrected by the previous employer. If you want to correct erroneous information, you must send the request for correction to the previous employer who provided this company with your information. Your previous employer, upon receiving your request, has fifteen days to correct the data. If the previous employer agrees to correct the data and notifies this company, there is no need for your previous employer to notify you. Your previous employer must keep this corrected information and can only supply this corrected information in the future. If you previous employer does not agree to correct the data, they must notify you within fifteen days of receiving your request.

You have the right to have a rebuttal statement attached to the alleged erroneous information, if you and your previous employer cannot agree on the accuracy of the information. You must send the rebuttal to the previous employer with instructions to include the rebuttal in your safety performance history. Within five business days of receiving your rebuttal, the previous employer must forward a copy of this rebuttal to this company and then it must attach your rebuttal to the disputed data for inclusion in your safety performance history. This rebuttal must be sent with all future requests for your employment information. You may submit a rebuttal without a request for correction or along with your request for a correction of the disputed employment history data.

You may report a previous employer's failure to incorporate rebuttal statements or corrected employment data into your safety performance history to the Federal Motor Carrier Safety Administration local office for your state.

Please note that we cannot process any application without consent.

I Understand DOT Rights:

________________________________________________________________

Certification

It is agreed and understood that this application for employment does not obligate Hometown Disposal Inc. to employ me. I affirm that I have a genuine intent and no other purpose in applying for a job with Hometown Disposal Inc.

I certify that any and all statements or information which I have set forth in this application are true and correct to the best of my knowledge. I also recognize that any misstatement or omission of facts on this application, in any supplement thereto, during any interview, or in any other company records supplied or completed by me shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I agree that, while this application is pending and before I begin any employment, I will provide information that did not exist when I filled out the application that might affect Hometown Disposal Inc.’s hiring decision. This includes, but is not limited to, being found guilty or pleading guilty to any crime and being terminated from current employment.

I understand that any offer of and my continued employment will be contingent on: (1) my submission of proof of eligibility to work in the United States; (2) my obtaining proper security clearance, if necessary; and (3) my successful completion of Hometown Disposal Inc.’s pre-employment checks. I understand and agree that employment with Hometown Disposal Inc. is voluntarily entered into and that my employment will be for no definite period of time and that my employment can be terminated at will with or without cause and with or without notice at any time at the option of either the Company or myself. I understand that no manager or representative of Hometown Disposal Inc. other than the President of the Company has any authority to enter into any permanent agreement for employment for any specified period of time or to make any agreement contrary to the foregoing and then only if the agreement is expressly set forth in a written document signed by me and by the President of the Company.

I understand and agree that, if I am employed with Hometown Disposal Inc., I will not engage in outside employment which interferes, competes, or conflicts with the interest of the Company.
Additionally, by signing below 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.
By my electronic signature below, I certify that I (1) have read and understand this certification page, (2) agree with the terms in it, and (3) have reviewed my application for accuracy.

*Electronic Signature:

________________________________________________________________

Authorization for Procurement of Consumer Report

For employment purposes, Hometown Disposal Inc. may obtain consumer reports and/or investigative consumer reports on you as an applicant or from time to time during employment. “Consumer reports” are reports from consumer reporting agencies and may include driving records, criminal records, and other personal information.

For such employment purposes, Hometown Disposal Inc. may also obtain investigative consumer reports. Some reference checks by a consumer reporting agency fall into this category. An “investigative consumer report” is a consumer report in which information as to character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with neighbors, friends, associates, acquaintances, or others. You have a right to request disclosure of the nature and scope of an investigation and to request a written summary of consumer rights.

I understand that Hometown Disposal Inc. may use the services of a consumer reporting agency to conduct a background investigation related to my application for employment. I also understand that if I am hired, Hometown Disposal Inc. may obtain further information through subsequent investigations by a consumer reporting agency during the course of my employment. I consent to these investigations and authorize Hometown Disposal Inc. to procure a consumer report and/or investigative consumer report, which includes personal interviews, on my background from a consumer reporting agency. I understand that any such investigation will be done in accordance with the Fair Credit Reporting Act and any applicable state law and acknowledge that I have been provided access to and/or read a copy of the document entitled “A Summary of Your Rights Under the Fair Credit Reporting Act” which is available at www.ftc.gov/credit

I certify that I (1) have read and understand this Authorization page, (2) agree with the terms in it, (3) have reviewed my application for accuracy, and (4) acknowledge my access provided to me of "A Summary of Your Rights Under the Fair Credit Reporting Act."

FCRA - I Agree:

________________________________________________________________

Authorization for Release of Information and Consent to Investigative and Drug Screen.

I authorize the release of any information related to my previous employment, criminal convictions, education, driving records, residences, or character, unless such information is restricted by law. I understand Hometown Disposal Inc. will only consider information that is pertinent to the position for which I have applied. I request that this document, or any duly executed copy of this document, serve as my authorization to any persons, companies, government agencies, authorized delegates, or other entities to furnish Hometown Disposal Inc. any and all such information pertaining to me that might be in their possession.

I agree to submit to alcohol and substance abuse screening (breath, saliva, urine, blood, and hair sampling). If I am employed, I agree to voluntarily submit to random alcohol and substance abuse screening (breath, saliva, urine, blood, and hair sampling) as a continuing condition of my employment. I further understand and agree that, if I refuse to submit to such screening, it shall be deemed misconduct and will result in disciplinary action, up to and including termination. I understand that, in the event that I am injured on the job and unable to give my consent for a controlled substance abuse/alcohol screen, by my signature on this document, I am providing consent, and I consent to the release to my employer all medical records pertaining to the injury, and / or the controlled substance abuse/alcohol screening which is necessary to document the absence or presence of alcohol and / or controlled substance in my body. I understand that, as a term and condition of employment, I am responsible for compliance with the Drug & Alcohol-Free Workplace Policy. Failure to comply, or a positive test result shall be deemed misconduct and will result in disciplinary action, up to and including termination.

I agree to furnish any additional information required to complete the pre-employment background investigation. I also agree to submit to a pre-employment drug screen.

I Agree:

*Date of Birth:

*Maiden or other names under which records may be listed:

________________________________________________________________

Voluntary Equal Opportunity Questionnaire.

As an equal opportunity employer, we hire without consideration to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, veteran status or disability. We invite you to complete the optional self-identification fields below used for compliance with government regulations and record-keeping guidelines. This information is for reporting purposes only and will not be considered in any way in evaluating your application for employment.

Gender:
MaleFemale

Race:
HispanicAfrican America/BlackAmerican IndianWhite/CaucasianMixedOther