Non-Driver Application

Name*
First Last
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physical Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email
Position Interested In / Applying For
Are you looking for permanent employment?
Have you ever worked for Pottle's Transportation, LLC before?
Past Addresses
List all addresses where you have lived over the previous three years. Include length of time at each address.
Emergency Contacts
Please provide name and telephone number of two persons to be notified in case of emergency.
Name
First Last
Phone
Relationship
Name
First Last
Phone
Relationship
Past Employers
List the names and address of all employers during the past ten years preceding the date of this application. Include your job description, date of employment and reason for leaving.
Most Recent / Current Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Held
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Supervisor / Foreman
First Last
Salary
Reason for leaving / reason for change
Name all relatives or friends employed presently or in the past with this company and your relationship
Second to Last Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Held
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Reason for Leaving
Third Last Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Held
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Reason for Leaving
Please continue work history below
Do you object to our checking with any of your past employers, or your present one?*
If so, please explain:
References
List three professional references (other than relatives), their occupation, address, telephone number and how long you have known them:
Reference #1 Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation
Phone
First met
MM slash DD slash YYYY
Last known
MM slash DD slash YYYY
Reference #2 Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation
Phone
First met
MM slash DD slash YYYY
Last known
MM slash DD slash YYYY
Reference #3 Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation
Phone
First met
MM slash DD slash YYYY
Last known
MM slash DD slash YYYY
Education History
High school name
Grade completed
Date completed
MM slash DD slash YYYY
Business/ trade school name
Years completed/ degree Earned
Date completed
MM slash DD slash YYYY
College name
Years completed/ degree Earned
Date completed
MM slash DD slash YYYY
Licensing
If applying for a maintenance position please list license number and state
Authentication & Completeness
It is agreed and understood that any misrepresentations of information given above shall be considered an act of dishonesty. It is also agreed and understood that the employer or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information. The applicant further agrees to furnish such additional information and complete such examinations as may be required to complete his employment file. It is agreed and understood that this application for employment in no way obligates the employer to employ the applicant. It is also agreed and understood that if hired, the employee may be on a probationary period during which time he may be discharged without recourse. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Name*
Date*
MM slash DD slash YYYY
Notification & Release, Consumer Report & DAC Services
In making this application for employment, it is understood that Pottle’s Transportation, LLC may request that a Consumer Report may be prepared which may include information as to my credit worthiness, credit standing, credit capacity, debts, check writing experience, insurability, character, general reputation and personal characteristics. Also being requested from DAC Services, Tulsa, Oklahoma, are consumer and background reports which may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such review may contain public record information concerning my driving record, worker’s compensation claims, credit, bankruptcy proceedings, etc. from federal, state and other agencies which maintain such records as well as information from DAC concerning (1) previous driving record requests made by others from such state agencies; (2) state provided driving records; (3) claims involving me in the files of insurance companies. I AUTHORIZE WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED TO FURNISH THE ABOVE MENTIONED INFORMATION. I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request; the sources of information; the receipts of any reports on me which DAC has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that such information which it has or obtains, and my employment history with you if I am hired will be supplied by DAC to other companies which subscribe to their services.
Name*
Date*
MM slash DD slash YYYY

Non-Driver Application

Non-Driver Application

Emergency Contacts

Past Employers

References

Education History

Licensing

Authentication & Completeness

Notification & Release, Consumer Report & DAC Services