Employment - Miner's Towing

Applicant Information
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, veteran status, non-job related disability, or any other protected group status.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to;  Review information provided by previous employers;  Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and  Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
Name
First Last
Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Date Available
MM slash DD slash YYYY
Social Security Number
Desired Salary
Position Applied For
Are you a citizen of the United States?
- YES
- NO
If no, are you authorized to work in the U.S.?
- YES
- NO
Have you ever worked for this company?
- YES
- NO
If yes, when?
Have you ever been convicted of a felony?
- YES
- NO
If yes, explain:

Education
High School
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From
To
Did you graduate?
- YES
- NO
Diploma
College
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From
To
Did you graduate?
- YES
- NO
Degree
Other
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From
To
Did you graduate?
- YES
- NO

References
Name
First Last
Relationship
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name
First Last
Relationship
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name
First Last
Relationship
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Previous Employment
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilites
From
To
Reason For Leaving
May we contact your previous supervisor for a reference?
- YES
- NO
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilites
From
To
Reason For Leaving
May we contact your previous supervisor for a reference?
- YES
- NO
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilites
From
To
Reason For Leaving
May we contact your previous supervisor for a reference?
- YES
- NO
Military Service
Branch
From
To
Rank at Discharge
Type of Discharge
If other than honorable, explain
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Disclaimer and e-signature*
I agree
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Applicant Information