Employment Application -

PERSONAL INFORMATION

Name

First Last

Phone

Email

Address

Street Address City State / Province / Region Country

ARE YOU A U. S. CITIZEN:

YES
NO

By signing this employment application you hereby consent to submit to a drug or alcohol test in order to meet Bonneville’s policy regarding the selection of applicants for employment. I further authorize to the release of the results of said tests to Bonneville Asphalt. I understand that it is the current use of illegal drugs that would prohibit me from being employed at this Company.

IF SELECTED FOR EMPLOYMENT ARE YOU WILLING TO SUBMIT TO A PRE-EMPLOYMENT DRUG SCREENING TEST:

YES
NO

POSITION

POSITION YOU ARE APPLYING FOR:

AVAILABLE START DATE:

How Did You Hear About Us?

Who Referred You?

Depending on the position you are hired to fill Bonneville Asphalt hires for full-time seasonal work. Weather impacts the work we do so we try to work as far into the winter as possible and start up as early in the spring as possible with some on-call work during the winter. We typically work about 9+ months of the year and the available hours are plenty during those months.

EMPLOYMENT DESIRED:

FULL TIME
PART TIME
SEASONAL OR TEMPORARY

EDUCATION

SCHOOL NAME	LOCATION	DATES ATTENDED	DEGREE RECEIVED	MAJOR

CURRENT & PREVIOUS 3 YEARS ADDRESSES

Address

FROM

TO

Address

FROM

TO

Address

FROM

TO

EMPLOYMENT HISTORY

EMPLOYER 1:

EMPLOYER: JOB TITLE:

DATES EMPLOYED:

FROM

TO

JOB DESCRIPTION:

Address

CITY

STATE

SUPERVISOR’S NAME & PHONE NUMBER: PAY RATE:

EMPLOYER 2:

EMPLOYER: JOB TITLE:

DATES EMPLOYED:

FROM

TO

JOB DESCRIPTION:

Address

CITY

STATE

SUPERVISOR’S NAME & PHONE NUMBER: PAY RATE:

EMPLOYER 3:

EMPLOYER: JOB TITLE:

DATES EMPLOYED:

FROM

TO

JOB DESCRIPTION:

Address

CITY

STATE

SUPERVISOR’S NAME & PHONE NUMBER: PAY RATE:

DRIVING EXPERIENCE / CERTIFICATION

CLASS OF EQUIPMENT

APPROX MILES

DATES: FROM

TO

STRAIGHT TRUCK:

TRACTOR & SEMI-TRAILER(S):

STICK SHIFT?

YES
NO

OTHER (SPECIFY):

In order to be compliant with UDOT our drivers must have a current Medical Examiners Certificate (Medical Card). This requires a physical exam that typically takes place at the same time as the pre-employment drug screening. By signing this employment application you hereby consent to a physical exam for the purpose of obtaining a medical card.

MEDICAL CARD EXPIRATION DATE:

LIST STATES OPERATED IN, FOR THE LAST FIVE (5) YEARS:

LIST SPECIAL COURSES/TRAINING COMPLETED (PTD/DDC,HAZMAT,ETC):

LIST ANY SAFE DRIVING AWARDS YOU HOLD AND FROM WHOM:

ACCIDENT RECORD FOR THE PAST THREE (3) YEARS:

DATE OF ACCIDENT	LOCATION OF ACCIDENT	NUMBER OF INJURIES

TRAFFIC CONVICTION AND FORFEITURES FOR THE LAST THREE (3) YEARS:

DATE	LOCATION	CHARGE	PENALTY

DRIVER’S LICENSE: LIST EACH DRIVER’S LICENSE HELD IN THE PAST THREE (3) YEARS:

STATE	LICENSE	TYPE	ENDORSEMENTS	EXPIRATION DATE

HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE?

YES
No

If ‘yes’ explain:

HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED?

YES
No

If ‘yes’ explain:

IS THERE ANY REASON YOU MIGHT BE UNABLE TO PERFORM THE FUNCTIONS OF THE JOB FOR WHICH YOU HAVE APPLIED FOR.

YES
No

If ‘yes’ explain:

DO YOU HAVE ANY SR22 FILINGS OR OTHER RESTRICITONS?

YES
No

If ‘yes’ explain:

HAVE YOU EVER BEEN CONVICTED OR A FELONY?

YES
No

If ‘yes’ explain:

I CERTIFY THAT MY ANSWERS ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. IF THIS APPLICATIN LEADS TO EMPLOYMENT, I UNDERSTAND THAT FALSE OR MISLEADING INFORMATION IN MY APPLICATION OR INTERVIEW MAY RESULT IN TERMINATION OF MY EMPLOYMENT

Name

First Last

Date

By submitting this application you are agreening to the terms herein and validity of your information you have provided.

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