Fields Marked With
* Are Mandatory
EMAIL ADDRESS *
TELEPHONE NUMBER *
Position(s) you are applying for
Age (If under 21)
Have you previously applied or worked for Border States Paving?
If yes, provide dates
Have you ever served in the military?
Branch of service
Rank at discharge
Length of service
If yes, describe in full
(Conviction of a felony does not automatically bar employment, circumstances will be considered)
If hired, can you provide proof that you can legally work in the United States?
(Proof of eligibility will be required upon employment)
List any friends or relatives other than spouse, currently employed at Border States Paving
How did you learn about our available position(s)?
Any restrictions on days/hours/weekends?
Are you willing to travel if required?
Are there specific days/hours that you cannot work?
JOB RELATED SKILLS
Truck Driver Experience
Equipment Operator Experience
Other Relevant Experience OR Special Training
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 responding to inquiries 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 safety performance history as required by 49 CFR 391.23(d) and (e). I understand I have the right to:
Review information provided by current/previous employers;
Have errors in the information corrected by previous employers and for those 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."
PAST THREE YEAR RESIDENCY
ADDITIONAL EMPLOYMENT HISTORY
Please list your employment history for a total of 10 years as required by FMCSR.
(If additional room is needed please send us a separate email to email@example.com).
EXPERIENCE AND QUALIFICATIONS
Do you have driving experience within the last 3 years?
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT
Check all that apply
Tractor & Semi-Trailer
Tractor & Two Trailers
ACCIDENT HISTORY (3 YEARS)
Have you had accidents within the last 3 years?
TRAFFIC CONVICTIONS AND FORFEITURES (3 YEARS)
Have you had traffic convictions and forfeitures within the last 3 years?
Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more that one driver's license." I certify that I do not have more than one motor vehicle license, the information for which is listed below:
Have you ever been denied a license, permit, or privilege to operate a motor vehicle? A. *
If yes, give details
Has any license, permit, or privilege ever been suspended or revoked? B. *
If yes, give details
49 CFR PART 40.25(J)
Release & Documentation of Pre-Employment Testing Information
by Driver/Applicant for Border States Paving, Inc.
OPTIONAL AFFIRMATIVE ACTION DATA FORM
Border States Paving, Inc. is committed to employing the most qualified applicants for available positions, regardless of race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, marital status or veteran status. In conjunction with that commitment, we have an Affirmative Action plan which is intended to encourage qualified women, veterans, minorities, and individuals with disabilities to apply for open positions. While special effort is made to encourage these individuals to apply,
all candidates are considered equally once they have applied.
To determine whether we have met our goals for encouraging women, minorities, veterans, and disabled individuals to apply, we need to gather related information from all our applicants. Please consider providing us with the information requested below.
Your participation is optional and your decision to provide or not to provide the information will in no way impact your consideration for the position. Furthermore, the information you provide will not be seen by the individuals evaluating your qualifications and determining whether or not you will be offered a position.
What position are you applying for?
How did you hear about this position?
(Select the most appropriate option
and provide source name if requested)
(Select the most appropriate box
to indicate your gender)
(Select the option that you
most closely identify with)
American Indian or Alaskan Native
Persons having origins in any of the original peoples of North, Central, or South America and who maintain tribal affiliation or community attachment.
Asian or Pacific Islander
Persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands.
Black/African-American (not of Hispanic origin)
Persons having origins in any of the Black racial groups of Africa.
Hispanic or Latino
Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
Persons having origins in multiple races.
White (not Hispanic origin)
Persons having origins in any of the original peoples of Europe, the Middle East, or North Africa.
(Do you consider yourself
as in any way disabled?)
(Select the most appropriate box
to indicate your status)
Other Protected Veteran
Armed Forces Service Medal Veteran
Recently Separated Veteran
I am not currently a Veteran
Voluntary Self-Identification of Disability
OMB Control Number 1250-0005
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.
To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.
Disabilities include, but are not limited to:
• Cerebral palsy
• Muscular dystrophy
• Bipolar disorder
• Major depression
• Multiple sclerosis (MS)
• Missing limbs or partially missing limbs
• Post-traumatic stress disorder (PTSD)
• Obsessive compulsive disorder
• Impairments requiring the use of a wheelchair
• Intellectual disability (previously called mental retardation)
Please check one of the options below:
YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON'T HAVE A DISABILITY
I DON'T WISH TO ANSWER
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.