APPLICATION FOR EMPLOYMENT

      In compliance with Federal and State equal employment opportunity laws, qualified applicants are
considered for all positions without regard to race, colour, religion, sex, national origin, age, ,marital status, or
the presence of a non-job related medical condition or handicap. 
 

    Date:  

      Position(s) applied for:

      Name (Last):

      Name (Middle):

      Name (First):

      Social Insurance No:

      Address:

      City:

      Province:

      Phone:

      Cell:

      Address for the past 3 years

      Street:

      City:

      Province & Postal Code:

      How long?

If you lived at the previous address for less than 3 years, please fill in below section

      Street:

      City:

      Province & Postal Code:

      How long?

      Are you 21 years or more and less than 65  years of age?        Please Select yes no  

      Can you provide proof of age?

      In case of emergency notify

      Name (first & last):

      Address:

      Phone:

  Have you worked for this company before?

Dates: From

To

Rate of Pay

Position Held

  Reason for leaving

  Are you now employed?

  If not, how long since leaving last place of  employment?                        

  Who referred you?

  Rate of pay expected:

Physical History

  List any handicap that prevents you from doing certain kinds of work

  Are you physically capable of heavy manual work?        Please Select Yes No

  Ever injured on the job?

  If yes, give the nature and degree of such injuries

 
  How much time lost from work in the past three years for illness?  

  Would you be willing to take a physical examination?                     Please Select Yes No  

  Have you ever?

  Tested positive for a controlled substance?

  Refused a drug test?

  Has a breath alcohol test greater than 0.04 for a company to which you applied but did not work for: Please Select Yes No
 

Employment History

Education

  Select the highest grade completed:

  High School:

  College:

  Last school attended:

Top ^^
 

Experience and Qualification - Driver

Province

License #

Class

Expiry Date

 (A) Have you ever been denied a license, permit or  privilege to operate a motor vehicle? Please Select Yes No  

 (B) Has any license, permit or privilege ever been  suspended or revoked?                         Please Select Yes No  

    
If the answer to either A or B is YES, please provide the details

Driving Experience

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 inquires of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools or personal from all liability in responding to inquires 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 regulation of the company, as permitted by law.

I agree with these terms and conditions

Certification of Compliance with Driver License Requirements

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighting 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:

A) You, as a commercial vehicle driver, may not posses more than one license. The only exception is if a state requires you to have more than one license. This exception is allowed until January 1, 1990.
If you currently have more than one license, you should keep the licensee from  your  state of residence and return the additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, you should close your record by notifying the state of issuance that you no longer want to be licensed by that state.

B) Part 392.42 and Part 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer to the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Part 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it to your employing motor carrier and the state that issued your license within 30 days.

DRIVER CERTIFICATION: I certify that I have read and understand the above requirements. The following license is the only one I possess:
Driver License No:     Province:     Expiry Date:

I agree that all information provided above is true and accurate

Medical Declarations

On March 30, 1999, transport Canada and U.S. Federal Highway Administration (FHWA) entered into a reciprocal agreement regarding the physical requirements for a Canadian driver of a commercial vehicle in the U.S., as currently contained in the Federal Motor Carrier Safety Regulations, Part 391.41 et seq, and vice-versa. The reciprocal agreement removes the requirement for a Canadian Driver to carry a copy of a medical examiner's certificate indicating that the driver is physically qualified. (In effect, the existence of valid driver's license issued by a province in Canada is deemed to be proof that a driver is physically qualified to drive in the U.S.) However, FHWA will not recognize a Provincial license if the driver has certain medical conditions and those conditions would prohibit him from driving in the U.S.

I certify that I am qualified to operate a commercial motor vehicle in the United States. I further certify that:

A) I have no clinical diagnosis of diabetes currently requiring insulin for control.

B) I have no established medical history or clinical diagnosis of epilepsy.

C) I do not have impaired hearing. (A driver must be able to first perceive a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid, or does not have an average hearing loos in the better ear greater than 40 decibels at 500Hz, 1000Hz, or 2000Hx with or without a hearing aid when tested by an audiometric device calibrated to American National Standard Z24.5-1951.)

D) I have not been issued a waiver by a Canadian province allowing me to operate a commercial motor behicle pursuant to Section 20 or 21 of Ontario Regulation 340/94.

I further agree to inform Sarnia Paving Stone Ltd. should my medical status ;change, or if I can no longer certify conditions 1 through D, described above.

Driver Name:
 

  I agree with the above regulations