EMPLOYMENT APPLICATION
All fields marked with * are required.
Personal Information

Are you applying for a company position or are you an owner operator? Company Owner Operator

If Owner Operator; list Make and year of your tractor:
First Name:
*
 Last Name:
*
Address:
*
City:
*
 E-Mail Address:
State:
*
Zip:
*
Phone:
*
XXX-XXX-XXXX		 Date of Birth:
MM/DD/YYYY


License Details

CDL Driver's License #: Expiration Date:
MM/DD/YYYY		 State:
Years of Experience: Hazardous Materials Endorsement: Yes No
Have you ever been convicted of a crime? Yes No
If yes, explain:
Was your license ever suspended/revoked? Yes No
When?
 Where?
Number of moving violations in the last 3 years:

Any accidents in the last 3 years? Yes No
When?

MM/DD/YYYY
Who was at fault?
Damage Amount:
Type of equipment operated and number of years each:
Van
Tanker
Flatbed
Other

Reference Name: Phone Number:
XXX-XXX-XXXX

*** NOTE: PLEASE DETAIL YOUR WORK HISTORY FOR LAST 10 YEARS ***

Current Employer Information

Current Employer: Position:
Dates of Employment...
From:
MM/DD/YYYY
To:
MM/DD/YYYY
Pay:
City: State:
Phone:
XXX-XXX-XXXX		 Contact:

Past Employer (1) Information

Past Employer: Position:
Dates of Employment...
From:
MM/DD/YYYY
To:
MM/DD/YYYY
Pay:
City: State:
Phone:
XXX-XXX-XXXX		 Contact:
Why did you leave?

Past Employer (2) Information

Past Employer: Position:
Dates of Employment...
From:
MM/DD/YYYY
To:
MM/DD/YYYY
Pay:
City: State:
Phone:
XXX-XXX-XXXX		 Contact:
Why did you leave?

Past Employer (3) Information

Past Employer: Position:
Dates of Employment...
From:
MM/DD/YYYY
To:
MM/DD/YYYY
Pay:
City: State:
Phone:
XXX-XXX-XXXX		 Contact:
Why did you leave?

Past Employer (4) Information

Past Employer: Position:
Dates of Employment...
From:
MM/DD/YYYY
To:
MM/DD/YYYY
Pay:
City: State:
Phone:
XXX-XXX-XXXX		 Contact:
Why did you leave?

I certify that I personally completed this application and that all of the information is true and correct. I authorize James Brown Contracting Inc. to conduct a thorough background investigation in accordance with state and federal law and authorize my previous employers to release any information requested by James Brown Contracting Inc. and hold them harmless of all liability from the release of said information. Also, in accordance with the provisions of 49 CFR Part 382.405 and 382.413, I hereby authorize and require my previous and/or current employers specifically listed by me on this application to release the results (including any refusal to test) of all drug and alcohol tests taken by me pursuant to the provisions of 49 CFR while in their employment to James Brown Contracting Inc. by whatever means is most expedient.


Copyright 2003 James Brown Contracting, Inc. All rights reserved.
6908 Chapman Rd. Lithonia, GA 30058
(770) 482-6521
General Manager: Michael Odum
Operations Manager: Kevin Slaughter