Application for Driver / Dispatch Coordinator Job Your First Name (required) Your Last Name (required) *Driver's License State: ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming *Driver's License Number: *Driver's License Expiration Date: *Has your license ever been suspended? YesNo If yes, explain where and why: *List driving violations from the past 5 years. If none, answer zero. *Are you over 21? ---YesNo Home Phone Number with Area Code: (If none, leave blank) *Mobile Phone Number with Area Code: *Street Address: *City & State: *Zip code: *Have you ever been charged with committing any crime or offense? ---YesNo If yes, what? *Are you a citizen of the United States? YesNo If not a citizen, are you prevented from becoming legally employed because of visa or immigration status? YesNo (If No, please explain): *Wage desired: How did you find out about this position?InternetTemporary staffing agencyIowa workforce developmentSomeone who works at Big Ten Rentals alreadyOther *When are you available to start work? Are you looking for Permanent or Seasonal employment? PermanentSeasonal *What is your availability (check all that apply)? DaysWeekendsHolidaysOvertime Maximum weight you are capable of lifting on a regular basis: Up to 20lbs20 to 50lbs50 to 75lbs *Are you currently employed? YesNo EDUCATIONAL BACKGROUND Are you currently in school? YesNo Highest grade of High School completed: 9th10th11th12th High School Name: High School Address: Name of College Trade or Business School attended: College, Trade or Business School address: List any other skills, special knowledge, qualifications or certifications: Upload Current Resume (If submitting resume, skip the Employment History portion of this form.) EMPLOYMENT HISTORY We will ask about your past three jobs. About your most recent job: Employer Name: Dates of Employment (month/year - month/year): Supervisor Name: Supervisor Phone Number: May we contact your supervisor? YesNo Your Job Title: Duties & Responsibilities: Wages: Reason for leaving: About the job before your most recent job: Employer Name: Dates of Employment (month/year - month/year): Supervisor Name: Supervisor Phone Number: May we contact your supervisor? YesNo Your Job Title: Duties & Responsibilities: Wages: Reason for leaving: About the job before: Employer Name: Dates of Employment (month/year - month/year): Supervisor Name: Supervisor Phone Number: May we contact your supervisor? YesNo Your Job Title: Duties & Responsibilities: Wages: Reason for leaving: References: Professional Reference Name: Professional Reference, Work Relationship: Professional Reference, Number of years they have known you: Professional Reference Phone Number: Anything else you want to tell us? *Your Email *I hereby agree to submit to any drug test required, whether prior to my employment or if employed by this company at any time thereafter. ---YesNo I certify that the information in the application is correct to the best of my knowledge. I understand that in order to be considered for employment, I will need to provide Big Ten Rentals with my social security number. By submitting this application, I hereby authorize all corporations, companies, credit agencies, schools, government agencies, persons, military service, and former employers to release information they may have about me to, Big Ten Rentals, Inc. or its agents and employees, and release all persons or companies from liability or responsibility from doing so. Further, I authorize the procurement of a consumer report, credit check and department of motor vehicle records. I understand that such a report may contain information about my background, character, and personal reputation. I understand that this notice will also apply to any future update reports. I understand any false answers, statements, or implications made by me on this application or other required documents shall be considered sufficient cause for denial of employment or discharge. Upon termination of my employment for whatever reason, I release this company from all liability for supplying any information concerning my employment to any potential employer. If requested, I will take a post job-offer physical examination and my employment, in the event I receive medical treatment for any condition, including a physical, psychological, emotional, or psychiatric condition that is job-related, I hereby authorize the limited release and exchange of such medical information relating to my condition between the treatment provider and a company-designated physician. I further understand this is an application for employment and no employment contract is being offered. I understand that if I am employed, such employment is for an indefinite period of time and the company may change wages, benefits, and conditions at any time. My employement is at will. No individual with the company is authorized to change the employment-at-will status except an officer of the company, who may do so only in writing. I have read and agree to the above.