Authorization for Employment Background Check

Applicant Name		Date of Application		
Social Security Number		Date of Birth		
Company	Elite Service Inc.	Position Applied For		

In compliance with Federal and State equal employment opportunity laws, qualified applications are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, no-job related disability, or any other protected group status.

To be read and signed by the applicant:
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history or 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 person from all liability in responding to inquiries and releasing information in connection with my application.
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 safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:
•	Review information provided by 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.
This certifies that all information included in my application for employment was completed by me and  that all entries on it and information included in it are true and complete to the best of my knowledge.

Signature ______________________________________________________________________________________
Print Name ____________________________________________________ Date ____________________________

Application for Employment
ATTN: Rebecca Yoder, Safety/HR Director
905 Stone Hill Road, Denver, PA 17517
FAX: 717-484-6007
EMAIL: rebecca@eliteattitude.com

Name		Social Security #		
Address		How Long?		Phone #	(        )	
Previous Addresses, last three years		
	
DOB*		* Required for driving/CDL positions		Application Date		
Position Desired		Rate of Pay desired			
EXPERIENCE								
Type of truck	Experience	Years: From/To	

	
								
In what states have you driven professionally?		
							
TRAFFIC VIOLATIONS:	Last 3 years						
Date	Location	Charge	Type of Vehicle	Points	

	
	
ACCIDENTS:	Last 3  years							
Date	Location	Description	Type of vehicle	Points	

	
	
Driver Licenses Held in Last 3 Years						
State:		Number:		Exp. Date:					
State:		Number:		Exp. Date:					
State:		Number:		Exp. Date:					
Has your license ever been suspended or revoked?		If yes, why & When?					
Have you ever been convicted of a felony?	                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           	If yes, date & nature of offense		
List all schools or training related to trucking that you have attended.					
	
Highest level of education completed		
Have you ever served in the Armed Forces? 		If yes, did you receive an honorable discharge?		
Are you a U.S. citizen?		If foreign national, do you have a valid green card?			
List states operated in at least 3 years		
List any skills or training you have that you consider relevant to this position				

	
	
Who should we contact in case of an emergency? 		
Phone Number(s) and Relationship:		
Where did you first hear about us?		
When is the best time to contact you and phone number (if not the same listed on page one, ie: cell phone, etc)?		
	
Do you have access to the internet?		Email address		
Did you see our web site (www.eliteattitude.com)?					
Do you have any suggestions to help us improve our site?		

Please fill out and attach the work history section. We will not contact your current employer until we talk to you.	
									
I certify that all information herein is true and correct. I also hereby authorize this company to perform all background checks and investigations necessary to verify the information that I have provided. I understand that falsification or omissions by me of pertinent information shall be grounds for declining my application or revoking my safety clearance if discovered after its issuance.	
Signed		Date		
	
I understand that I have provided this information so that the company may determine whether I meet their safety and experience criteria. I also understand that decisions based on this information are provisional and that final decision is contingent upon my successfully passing a physical and drug screen as provided for in federal regulations.	
Signed		Date		

List all employment during the last 3 years and any driving experience in the last 10 years.
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Address		
Phone		Dates employed FROM		TO		
Position		Reason for leaving		

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