A COPY OF YOUR DRIVER’S LICENSE AND SOCIAL SECURITY
CARD WILL BE NEEDED.

HARTY TRACTOR SERVICE INC.
924 E. Rhode Island Ave.
P.O. Box 741674
Orange City, FL 32774-1674

(386) 775-1005

APPLICATION FOR EMPLOYMENT

(Answer all questions- please print)

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.

My E-mail Address is: Date of Application

Position(s) applied for

Last Name First Name Middle

Social Security # Telephone Number

List Current Address:

street
city
state
zip
how long

List Previous Addresses:

street
city
state
zip
how long

street
city
state
zip
how long

street
city
state
zip
how long

Do you have the legal right to work in the United States?

Date of Birth Can you provide proof of age?

(Required for Commercial Drivers)

Do you have any relatives working at Harty Tractor? If yes, name?

Have you worked for this company before? Where?

Dates:  From To Rate of Pay

Position

Reason for leaving

Are you now employed? If not how long since leaving last employment?

Who referred you? Rate of Pay expected  

Is there any reason you might be unable to perform the functions of the job for which you have applied?

If yes, explain if you wish.

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the proceeding 3 years. List complete mailing address, street number, city, State and zip code.

Applicants to drive a commercial motor vehicle* in interstate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.

(NOTE: List employers in reverse order starting with the most recent. Add another sheet if necessary.)

EMPLOYER

DATE

NAME

From mm/yy
To mm/yy

ADDRESS

Position held

CITY           STATE                ZIP

Salary /Wage

CONTACT PERSON PHONE #

Reason for leaving

EMPLOYER

DATE

NAME

From mm/yy
To mm/yy

ADDRESS

Position held

CITY            STATE             ZIP

Salary /Wage

CONTACT PERSON PHONE #

Reason for leaving

EMPLOYER

DATE

NAME

From mm/yy
To mm/yy

ADDRESS

Position held

CITY            STATE             ZIP

Salary /Wage

CONTACT PERSON PHONE #

Reason for leaving

EMPLOYER

DATE

NAME

From mm/yy
To mm/yy

ADDRESS

Position held

CITY            STATE             ZIP

Salary /Wage

CONTACT PERSON PHONE #

Reason for leaving

EMPLOYER

DATE

NAME

From mm/yy
To mm/yy

ADDRESS

Position held

CITY            STATE             ZIP

Salary /Wage

CONTACT PERSON PHONE #

Reason for leaving

EMPLOYER

DATE

NAME

From mm/yy
To mm/yy

ADDRESS

Position held

CITY            STATE             ZIP

Salary /Wage

CONTACT PERSON PHONE #

Reason for leaving

EMPLOYER

DATE

NAME

From mm/yy
To mm/yy

ADDRESS

Position held

CITY            STATE             ZIP

Salary /Wage

CONTACT PERSON PHONE #

Reason for leaving

* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE.

DATES

NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)

FATALITIES

INJURIES

LAST ACCIDENT

NEXT PREVIOUS

NEXT PREVIOUS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

LOCATION

DATE

CHARGE

PENALTY

(ATTACH SHEET IF MORE NEEDED)

EDUCATION

CIRCLE HIGHEST GRADE COMPLETED (1-8): HIGH SCHOOL (1-4): COLLEGE (1-4):

LAST SCHOOL ATTENDED City

EXPERIENCE AND QUALIFICATIONS – DRIVER

DRIVER

STATE

LICENSE NO.

TYPE

EXPIRATION DATE

LICENSES
 
 
 

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

B. Has any license, permit or privilege ever been suspended or revoked?

IF THE ANSWER TO EITHER A OR B IS YES, PROVIDE DETAILS

DRIVING EXPERIENCE IF NONE, WRITE NONE

CLASS OF EQIPMENT

TYPE OF EQUIPMENT(VAN,TANK,FLAT,ETC)

DATES

FROM

DATES

TO

APPROX NO. OF MILES (TOTAL)

STRAIGHT TRUCK

TRACTOR AND SEMI-TRAILER

TRACTOR –TWO TRAILERS

MOTORCOACH-SCHOOL BUS

OTHER

LIST STATES OPERATED IN THE LAST FIVE YEARS.

SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER.

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

EXPERIENCE AND QUALIFICATIONS – OTHER

SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION

LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)

________________________________________________________________________________________________________________________

TO BE READ AND SIGNED BY APPLICANT

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.

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 in responding to inquiries and releasing information in connection with my application.

We require you to sign the following when you bring in your application: - Fair Credit Reporting Act and authorization to procure reports such as driving record for assessment of insurability.

 

FOR OFFICE USE ONLY
PROCESS RECORD

APPLICANT HIRED___________________________ REJECTED___________________________________________________

DATE EMPLOYED___________________________ POINT EMPLOYED___________________________________________

DEPARTMENT________________________________ CLASSIFICATION ________________________________________

(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)

 

THIS SECTION TO BE FILLED IN BY RESPONSIBLE

OFFICER OR COMPANY REPRESENTATIVE

SUPERIOR
GOOD
FAIR
BELOW AVERAGE
POOR
WRITTEN RECORD ONFILE

1. APPLICATION

            

2. INTERVIEW

            

3.PAST EMPLOYMENT

            

4. WRITTEN EXAM

            

5. ROAD TEST

            

6. CRIMINAL AND TRAFFIC CONVICTIONS

            
             

SIGNATURE OF INTERVIEWING OFFICER________________________________________________________________________________________________________________________________________________________________________

TRANSFERE

FROM:_____________________TO:________________ FROM: ____________________ TO:_____________________________

DATE:_________________________________________ DATE:______________________________________________________

REASON FOR TRANSFER________________________ REASON FOR TRANSFER____________________________________

____________________________________________________________________________________________________________

FROM:_____________________To:________________ FROM:____________________ TO:_____________________________

DATE:_________________________________________ DATE:_____________________________________________________

REASON FOR TRANSFER________________________ REASON FOR TRANSFER____________________________________

__________________________________________________________________________________________________

TERMINATION OF EMPLOYMENT

DATE TERMINATED____________________________________DEPARTMENT RELEASED FROM__________________________________

DISMISSED________________VOLUNTARILY QUIT________________OTHER_____________________________

TERMINATION REPORT PLACED IN FILE_______________SUPERVISOR_________________________________