Mesilla Valley Transportation

Online Driver Application

Employment Record

Please answer this section:

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.

* Required Information

* Date:
* Name:
* Surname:
* Social Security No.:
* Date of Birth:

Email:
* Phone:
* Street Address:
* City, State, Zip:	,
* Position for which you are applying:

First Previous

Position start date:
Position end date:
Phone:
Contact:
Type of Equipment Driven:
Employer:
Name:
May We Call?	Yes No
Address:
Position Held:
Reason for Leaving:

Second Previous

Position start date:
Position end date:
Phone:
Contact:
Type of Equipment Driven:
Employer:
Name:
May We Call?	Yes No
Address:
Position Held:
Reason for Leaving:

Vehicle
Type

Nature of Accident

Preventable?

Facilities

Amount of
Damage

Have you worked for this company before?	Yes No
Have you ever been denied a license, permit or privilege to operate a motor vehicle?	Yes No
Have you ever been stopped while intoxicated?	Yes No
Have you ever been convicted for possession, sale, or use of a narcotic, drug, amphetamine or a derivative thereof?	Yes No
Have you ever been convicted of a criminal offense? (A conviction wil not necessarily disqualify you for employment.)	Yes No

If you answered yes to any of the above questions, state circumstances and dates below.

Licenses
List all driver's licenses held in the past five years.

* State	* License Number	Endorsements	* Expiration Date

Moving Traffic Convictions
List for past three years. If none, write "none."

Date	State	Charge	Penalty

Accident Record
List all involvement with truck and car including property damage for past five years. If none, write "none."

Additional Information

This information and any files or e-mail transmitted with it are the property of Mesilla Valley Transportation, confidential and are intended solely for the use of the individual to whom this email is addressed. Any other use, retention, dissemination, forwarding, printing or copying of this information is strictly prohibited.