Blachowske Truck Line

It is extremely important to give all information asked for when completing the applications and forms. This includes telephone numbers for your former employers. Also, please include work history for the past ten years, both driving and non-driving employment.

Please look at the form titled: "PDF Release Form". DO NOT FILL IN ANY OF THE BLANKS. YOU NEED ONLY TO SIGN AND DATE IT AT THE BOTTOM. This form allows Blachowske Truck Line and/or employee leasing company to verify your employment history.

Application For Employment

LAST NAME:

FIRST NAME:

MIDDLE INTL:

CURRENT ADDRESS:

CITY:

STATE:

ZIP:

PHONE#:

CELL PHONE#:

E-MAIL ADDRESS:

WEIGHT:

HEIGHT:

INCHES

BIRTH DATE:

SOCIAL SECURITY#:

CDL CLASS A DRIVERS LICENSE #:

STATE:

QUESTIONS
HAVE YOU WORKED FOR THIS COMPANY BEFORE:
WHO REFERED YOU IF ANYONE:
NUMBER OF YEARS EXPERIENCE:
NUMBER OF TICKETS IN THE PAST THREE YEARS:
NUMBER OF ACCIDENTS IN PAST THREE YEARS
HAVE YOU EVER BEEN CONVICTED OF A FELONY:

PHYSICAL HISTORY

DO YOU HAVE ANY PHYSICAL CONDITIONS WHICH MAY
LIMMT YOUR ABILITY TO PREFORM THE JOB APPLIED FOR?

IF YES WHAT C AN BE DONE TO ACCOMMODATE LIMITATIONS?

ARE YOU PHYSICALLY CAPABLE OF HEAVY, MANUAL WORK?

HOW MUCH TIME HAVE YOU LOST FROM WORK IN THE PAST THREE YEARS

WOULD YOU BE WILLING TO TAKE A PHYSICAL EXAMINATION?

EMPLOYMENT HISTORY
NAME:
ADDRESS:
CITY:
STATE:	ZIP:	CONTACT PERSON:
PHONE:	FROM:	TO:
POSITION:		WAGE:
REASON FOR LEAVING:

NAME:
ADDRESS:
CITY:
STATE:	ZIP:	CONTACT PERSON:
PHONE:	FROM:	TO:
POSITION:		WAGE:
REASON FOR LEAVING:

NAME:
ADDRESS:
CITY:
STATE:	ZIP:	CONTACT PERSON:
PHONE:	FROM:	TO:
POSITION:		WAGE:
REASON FOR LEAVING:

NAME:
ADDRESS:
CITY:
STATE:	ZIP:	CONTACT PERSON:
PHONE:	FROM:	TO:
POSITION:		WAGE:
REASON FOR LEAVING:

NAME:
ADDRESS:
CITY:
STATE:	ZIP:	CONTACT PERSON:
PHONE:	FROM:	TO:
POSITION:		WAGE:
REASON FOR LEAVING:

ACCIDENT RECORD PAST 3 YEARS
LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS

TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 3 YEARS
LOCATION, DATE, CHARGE:
LOCATION, DATE, CHARGE:
LOCATION, DATE, CHARGE:
LOCATION, DATE, CHARGE:

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

WE AT BLACHOWSKE TRUCK LINE INC. WILL NEED TO VERIFY PAST EMPLOYMENT HISTORY. FOR US TO DO THIS WE WILL NEED YOU TO SIGN AND DATE A RELEASE FORM. YOU MAY CONTACT US AT 866-552-2167 AND REQUEST A FAXED FORM. YOU MAY ALSO EMAIL US AT ericm@blachowske.com FOR AN EMAILED RELEASE FORM. THE FINAL OPTION IS TO PRINT THIS PDF FILE AND FAX IT BACK TO US AT 605-582-7957. Click Here For PDF Release Form

By submitting this application, I hereby certify that all of the information is correct and complete to the best of my knowledge. I authorize Blachowske Truck Line, Inc. to obtain information concerning my past and current work history, and to do a complete background investigation in accordance with State and Federal Laws. I authorize my previous employers to release any information requested by Blachowske Truck Line, Inc. and hereby release all such persons from any liability or damages. I have completed this application of my own free will and hold Blachowske Truck Line, Inc. and its employees harmless for all liability or damages for providing this application for my use.