Reliant Holdings Ltd. Company Web Site

Application for Employment

Reliant Employment Services, LTD
8590 County Road 12 1/2
(432) 617-4251
Pampa, Texas 79065
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.

Date of this Appication:
Position you are applying for:
First Name:		Last Name:
SSN:		Date of Birth (Required for Commercial Drivers Only):
Driver's License Class:		Driver's License No:
License State:		Expires:
Endorsements: (mark all that apply) None P-Passenger T-Double/triple trailer N-Tank Vehicles H-Hazardous Materials X-Tank Vehicle & Hazardous Materials Restrictions:
Current Address:			City:
State:	Zip:
Email Address:
Telephone:
Alternate:
How long at current address?: Years: Months:
If you have not lived at the above address for the past three years or longer, please list former addresses for the previous three years:
Address:			City:
State:	Zip:
How long? Years: Months:

Address:			City:
State:	Zip:
How long? Years: Months:

Address:			City:
State:	Zip:
How long? Years: Months:

If hired, do you have the legal right to work in the United States?: yesno
Can you provide proof of age?:yesno
Have you worked for this company before?:yesno
If yes, where?:
Dates: From To		Rate of pay:
Position:	Reason for Leaving:

Are you employed now?:yesno
If yes, may we contact your present employer?:yesno
If no, how long since leaving your last employment?:
Who referred you?:
Rate of pay you would expect: per (hour, day, week or month):

Is there any reason you might be unable to perform the functions of the job for which you have applied?:yesno(Note: if in doubt, please ask for a description of the complete duties you would be expected to perform in regard to the position you are applying for). If yes, explain if you wish:

Have you ever been convicted of a felony or misdemeanor charge?:yesnoIf yes, please list (Note: Convictions will not necessarily disqualify applicant):

EDUCATION
Highest grade completed: 123456789101112N/A College:1234N/A
Name of last school attended:			Year:
City:		State:
Please list any areas of special study that would be applicable to the position you are applying for:

MILITARY STATUS
Have you served in the US Armed Forces?:yesno
If yes, Branch:		Date of Entry:
Rank at time of discharge:		Date of Discharge:
(In New Jersey fill in this line until hired) Draft Status:Reserve Status:

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding three (3) years. Please list the complete mailing address, contact person, and telephone number.

All applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an addition seven (7) years of information on those employers for whom the applicant operated such vehicles.

(Note: Please list employers in reverse order, starting with the most recent.)

Employer Name:
Dates From: To:
Street:	Position Held:
City:	State:	Zip:
Salary/Wage:
Reason for Leaving:
Contact Person:
Telephone Number:

Employer Name:
Dates From: To:
Street:	Position Held:
City:	State:	Zip:
Salary/Wage:
Reason for Leaving:
Contact Person:
Telephone Number:

Employer Name:
Dates From: To:
Street:	Position Held:
City:	State:	Zip:
Salary/Wage:
Reason for Leaving:
Contact Person:
Telephone Number:

Employer Name:
Dates From: To:
Street:	Position Held:
City:	State:	Zip:
Salary/Wage:
Reason for Leaving:
Contact Person:
Telephone Number:

Employer Name:
Dates From: To:
Street:	Position Held:
City:	State:	Zip:
Salary/Wage:
Reason for Leaving:
Contact Person:
Telephone Number:
If you need more room to complete employment history, click here:

Driving History

PREVIOUS DRIVING EXPERIENCE

Have you been employed as a driver by other motor carriers prior to the date of this application? yesno

If yes, how long did you operate the following?:
Straight Trucks:		Tractor, semi-trailer:
Tractor, double trailers:		Tankers (semi):
Oil Field trucks:		Other:
Have you handled hazardous materials?:yesno
If yes, please describe:

ACCIDENT RECORD
List all accidents in which you were involved as a driver in the past five (5) years:
DATE	DESCRIPTION	INJURIES/FATALITIES






TRAFFIC VIOLATION RECORD
List all violations of motor vehicle laws or ordinances (other than parking) of which you were convicted, paid fines, or forfeited bond or collateral during the past three (3) years:
DATE	TYPE	LOCATION






A. Have you ever been denied a license, permit or priviledge to operate a motor vehicle?:yesno
B. Has your license, permit or privilege to drive ever been revoked or suspended?:yesno
If yes to one of the above two questions ("A" or "B"), please explain:

Notice/Authorization to Obtain Information

Notice/Authorization to Obtain Information
Part I - DOT Drug and Alcohol Release

**This must be filled out by all those applying to become a driver.**

Prospective Employer:

Reliant Transportation, Ltd
8590 County Road 12 1/2
Pampa, TX 79065

Phone: (432) 617-4270 - Safety Department
Secure Fax: (806) 828-0167

1. During the past three years, have you ever:

a) Had an alcohol test with a result of 0.04 or higher? YesNob) Had a verified positive drug test?
YesNoc) Refused to be tested?YesNo

2. If yes to any of the above, have you successfully completed a DOT Substance Abuse Program requirement?YesNo

I authorize, per 49 CFR Part 40, the release of information from my DOT regulated drug and alcohol testing records by the carriers (company/school) listed below for the sole purpose of transmitting such records to the above listed employer. I authorize release of the following information concerning DOT drug and alcohol testing violations during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug test; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation(s); and (vi) documents, if any, of completion of a return-to-duty process following a rule violation.

The information that I have authorized involves tests required by DOT. If any carrier (company/school) listed below furnishes information concerning items (i) through (vi) above, I also authorize that carrier (company/school) to release and furnish the dates of negative drug and/or alcohol tests and/or tests with results below 0.04 during the three-year period and the name and phone number of any substance abose professional who evaluated me during the past two years.

Company	City	State

Name:

Social Security No:

Disclosure and Authorization

Disclosure and Authorization
to Employees and Prospective Employees
to Obtain Information

**This must be filled out by all applicants**

The applicant agrees to furnish such additional information and complete such examinations as may be required to complete his/her employment file.

This application for employment does not obligate Reliant Employment Services, Ltd. to employ this applicant. In the event this applicant should be hired, the employment will be on a probationary period during which time he may be discharged without recourse.

In consideration for you furnishing such information, I specifically waive any confidentiality relationship or privacy position which may exist between us and completely release you from any responsibility or liability for damages which may occur as the result of the disclosre of truthful information.

A photocopy or any other copy of this instrument bearing my signature shall be equally and legally valid as the original.

In connection with evaluating me for employment, promotion, reassignment or retention as an employee, Reliant Employment Services, Ltd., may obtain a consumer report containing information regarding claims and lawsuits, driving history, criminal history, education and/or credit.

I understand I have the right to request information regarding the nature and scope of the investigation requested.

The Fair Credit Reporting Act gives me specific rights in dealing with consumer reporting agencies. I understand I will be given a summary of these rights with this document. I acknowledge receipt of this disclosure and my rights under the Fair Credit Reporting Act.

By my electronic signature below, I certify 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 do hereby authorize Reliant Holdings Ltd., Reliant Employment Services Ltd., Reliant Transportation Ltd. and their affiliates to perform a background check on my background, including the procurement of the following reports and information:

Examination of documents and record keeping required by federal immigration laws;
Verification of my employment history for the past five (5) years;
Verification of my education records for the highest degree I have received;
Check of court records during the past seven (7) years in all counties in which I have resided for the last seven (7) years;
Review of Department of Motor Vehicle records;
Examination of the federal Food and Drug Administration Debarment List, the federal Food and Drug Administration Restricted List, and the federal Department of Health and Human Services - Office of Inspector General Exclusion List;
Credit check where my job assignment involves financial or money-related functions;
Check of records of criminal convictions;
Check of arrest records during the past seven (7) years.
Access the FMCSA Pre-Employment Screening Program(PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years

Name:

Social Security No: