Application for Employment

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.

Applications must be filled out with as much information as possible. Incomplete applications will not be considered.

Date of Application:

Position(s) Applied for:

Name:

Social Security Number:

Date of Birth:

Contact Info:

Current Address:

Upload Resume or Cover Letter:

Past 2 Years of Residency

Past Address:

+ Add Additional Residence

Past Address:

Do you have the legal right to work in the United States?

Yes No

Are you employed?

Yes No

If not, how long since leaving last employment?

Who referred you?

Rate of pay expected?

Is there any reason you might not be unable to perform the functions of the job for which you have applied (as described in the job description)?

Yes No

If yes, explain if you wish:

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing, street number, city, state and zip code. Account for all periods between employment.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle.

(Note: List employers in reverse order starting with the most recent.)

Employer Name:

Date Employed (From):

Date Employed (To):

Position Held:

Salary/Wage:

Reason for Leaving:

Employer Contact:

+ Add Additional Employment

Employer Name:

Date Employed (From):

Date Employed (To):

Position Held:

Salary/Wage:

Reason for Leaving:

Employer Contact:

Employer Name:

Date Employed (From):

Date Employed (To):

Position Held:

Salary/Wage:

Reason for Leaving:

Employer Contact:

Accident Record For Past 3 Years

Select if you had no accidents for the past 3 years

Date of Last Accident:

Fatalities:

Injuries:

Nature of Accident:

+ Add Additional Accident

Date of Accident:

Fatalities:

Injuries:

Nature of Accident:

Date of Accident:

Fatalities:

Injuries:

Nature of Accident:

Traffic Convictions and Forfeitures For Past 3 Years

Select if you had no traffic convictions for the past 3 years - Do not include parking violations.

Date:

Location:

Charge:

Penalty:

+ Add Additional Conviction

Date:

Location:

Charge:

Penalty:

Date:

Location:

Charge:

Penalty:

Education

Last School Attended:

Experience and Qualifications - Driver

Driver License:

Additional Driver License:

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes No

Has any license, permit or privilege ever been suspended or revoked?

Yes No

If the answer to either is Yes, please give some details:

Driver Experience

Select if you have no driver experience

Type of Equipment:

Date (From):

Date (To):

Approx. No. of Miles:

+ Add Additional Experience

Type of Equipment:

Date (From):

Date (To):

Approx. No. of Miles:

Type of Equipment:

Date (From):

Date (To):

Approx. No. of Miles:

List states operated in for last 5 years:

Special courses or training that will help you as a driver:

Which safe driving awards do you hold and from whom?

Experience and Qualifications - Other

Show any trucking, transportation, or other experience that may help you work for this company:

List of courses and training other than shown elsewhere in this application:

List special equipment or technical materials you can work with:

To Be Read by Applicant

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquires and releasing information 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 regulations of the Company.

“I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safe performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

Review information provided by current/previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.”

I understand I will be required to successfully pas a pre-employment drug screening examination. I also understand that I will be entered into the Companies drug and alcohol testing program including pre-employment, post incident, and reasonable suspicion testing. I hereby consent to this pre-employment test and to any testing required for participation in this program. If my application is for a position that requires a Commercial Driver’s License (CDL), I further understand that I will also be entered into the federally mandated drug and alcohol testing program that includes pre-employment, post incident, reasonable suspicion and random drug and alcohol testing. I hereby consent to this pre-employment test and any testing required for participation in this program.

In the event of employment, I understand that false or misleading information given in my application or interviews may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.

Electronic Signature Agreement. By selecting the "Submit Application" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide The Wine Wrangler, Inc., or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you The Wine Wrangler, Inc.

Full Name:

Date:

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