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Allegiance Expanded Employment Application

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Please Choose Application Type:

DOT

Non-DOT

Last Name

First Name

Date of Application

MM slash DD slash YYYY

Present Address

Street Address Address Line 2 City State ZIP Code

How long have you lived there?

How long have you lived there? (Years)

How long have you lived there? (Months)

Previous Address

Street Address Address Line 2 City State ZIP Code

How long did you lived there?

Previous Residence Time (Years)

Previous Residence Time (Months)

Telephone Number

Social Security Number

Are you 18 years of age?

Yes

No

Placement Desired

Full Time

Part Time

Temporary

Position Desired

When are you available to start?

Background Information

List any other names which you may have used and which will be necessary to verify your prior employment

Have you ever been terminated or asked to resign from any job?

Yes

No

If yes, please explain:

May we contact your current employer?

Yes

No

If no, please explain:

Have you ever worked for Allegiance Crane & Equipment Crane & Equipment before?

Yes

No

Allegiance Employment Date:

MM slash DD slash YYYY

Allegiance Employment Position:

MM slash DD slash YYYY

Do you have any friends or relatives working here or for one of our other companies?

Yes

No

How did you hear about this job opportunity?

Do you have any commitments to any other employer which may affect your employment?

Yes

No

If yes please explain:

NOTE: Answering yes" to the following questions does not constitute an automatic disqualification. If you answer yes to any of the preceding questions, please give dates and details:

Have you ever plead "no contest" nolo, or guilty to a crime, or been convicted of a crime?

Yes

No

Please explain (give dates and details):

Are any charges currently pending against you?

Yes

No

Education

Elementary

Years Completed

Diploma/Degree

Describe Specialized Experience, Training, Skills, and Extra-Curricular Activities

High School

Years Completed

Diploma/Degree

Describe Specialized Experience, Training, Skills, and Extra-Curricular Activities

College/University

Years Completed

Diploma/Degree

Describe Specialized Experience, Training, Skills, and Extra-Curricular Activities

Graduate/Professional

Years Completed

Diploma/Degree

Describe Specialized Experience, Training, Skills, and Extra-Curricular Activities

Trade or Correspondence

Years Completed

Diploma/Degree

Describe Specialized Experience, Training, Skills, and Extra-Curricular Activities

List other qualifications, experiences, licenses, certifications, etc., that you consider pertinent to the job applied for:

Do you have a current valid driver's license?

Yes

No

Has your license been suspended or revoked?

Yes

No

If yes, explain:

Employment History

Present or most recent employer

Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Job Titles

Duties and Responsibilities

Supervisor's Name

Supervisor's Title

Supervisor's Phone

Date Employed From:

MM slash DD slash YYYY

Date Employed To:

MM slash DD slash YYYY

Starting Base Salary:

Final Base Salary:

Commissions:

Bonus:

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations while employed by the previous employer?

Yes

No

Was the previous job description designated as safety sensitive function in any DOT regulated mode. subject to alcohol and controlled substance tesling requirements as required by 49 CFR Part 40?

Yes

No

Past employer

Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Job Titles

Duties and Responsibilities

Supervisor's Name

Supervisor's Title

Supervisor's Phone

Date Employed From:

MM slash DD slash YYYY

Date Employed To:

MM slash DD slash YYYY

Starting Base Salary:

Final Base Salary:

Commissions:

Bonus:

Reason For Leaving

Were you subject to the Federal Motor Carrier Safety Regulations while employed by the previous employer?

Yes

No

Was the previous job description designated as safety sensitive function in any DOT regulated mode. subject to alcohol and controlled substance tesling requirements as required by 49 CFR Part 40?

Yes

No

Past employer

Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Job Titles

Duties & Responsibilities

Supervisor's Name

Supervisor's Title

Supervisor's Phone

Date Employed From:

MM slash DD slash YYYY

Date Employed To:

MM slash DD slash YYYY

Starting Base Salary:

Final Base Salary:

Commissions:

Bonus:

Reason For Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations while employed by the previous employer?

Yes

No

Was the previous job description designated as safety sensitive function in any DOT regulated mode. subject to alcohol and controlled substance tesling requirements as required by 49 CFR Part 40?

Yes

No

Please explain any time lapse between jobs:

References

Please provide the names of 3 business references you are not related to, whom you have known at least 1 year.

Reference #1

Name:

Business Relationship:

Business:

Phone or Email:

Reference #2

Name:

Business Relationship:

Business:

Phone or Email:

Reference #3

Name:

Business Relationship:

Business:

Phone or Email:

Crane Operators

If you are a licensed crane operator, please list your details below:

Crane Operator License #1

State/Certificate Body

License #

Class Type

Expiration Date

MM slash DD slash YYYY

Crane Operator License #2

State/Certificate Body

License

Class Type

Expiration Date

MM slash DD slash YYYY

Equipment Experience

Please check all equipment types you have experience operating:

Boom Truck

Hydraulic Crane

Tower Crane

Other

Boom Truck

Type of Equipment

Dates Operated

MM slash DD slash YYYY

Hours Operated

Hydraulic Crane

Type of Equipment

Dates Operated

MM slash DD slash YYYY

Hours Operated

Tower Crane

Type of Equipment

Dates Operated

MM slash DD slash YYYY

Hours Operated

Other Equipment

Type of Equipment

Dates Operated

MM slash DD slash YYYY

Hours Operated

Signature & Acknowledgement

"By executing and submitting this application, I certify that I am genuinely interested in working in the position(s) for which I have applied and am making this application for no other purpose."

"I hereby certify that the answers given above are true and correct. I understand that any misrepresentation in this application or in any other document submitted to Allegiance Crane & Equipment is sufficient grounds for disqualification of the applicant or, if discovered after the applicant is hired, for discharge. I hereby grant Allegiance Crane & Equipment permission to investigate information included in this application. I agree, as part of the employment process, that any offer of employment extended by Allegiance Crane & Equipment is subject to successfully passing a drug/alcohol screen which may include blood testing, urinalysis, etc. for the purpose of detecting alcohol, drugs, or substances of abuse. I further agree after employment to submit to a medical examination and/or a drug screen when requested by Allegiance Crane & Equipment in accordance with company policies."

"In connection with the processing of this application, Allegiance Crane & Equipment and/or their agents, may contact my current and former employers, my listed references, and my schools to obtain more information about me and I authorize and release from all liability those persons to give Allegiance Crane & Equipment any information regarding my employment, character, safety performance (as required by 49 CFR 391.23[d] and (el), and qualifications, together with any information they may have regarding me whether or not it is in their records. Allegiance Crane & Equipment may also contact any investigative, criminal, credit or consumer reporting agency to obtain information concerning my character, general reputation, personal characteristics, and mode of living. I understand that all offers of employment extended by Allegiance Crane & Equipment are subject to investigations described above, and that such investigations may not be completed until after I am hired. Should employment be denied or terminated, either wholly or partly, because of information obtained from this report before or after I am hired, Allegiance Crane & Equipment will advise me of that fact and provide the name and address of the investigative, credit or consumer reporting agency making the report. "

"If hired by Allegiance Crane & Equipment, I agree that all right, title and interest, including, without limitation, all copyrights and patents, in and to any intellectual property produced or inventions developed by me which affect or relate to Allegiance Crane & Equipment's business or affect or relate to the crane industry shall vest in Allegiance Crane & Equipment and I shall have no personal right, title or interest whatsoever therein."

"I understand and agree that, if hired by Allegiance Crane & Equipment, I will be subject to Allegiance Crane & Equipment's employment policies, as may be amended from time-to-time by Allegiance Crane & Equipment, in its sole discretion. I further agree to keep confidential all information I may be exposed to or come to learn as a result of any employment with Allegiance Crane & Equipment."

"I understand that, any employee hired by Allegiance Crane & Equipment is hired as an employee-at-will who may be terminated without cause or notice at any time, except for those employees covered by collective bargaining agreements, at the sole option of Allegiance Crane & Equipment. No one at Allegiance Crane & Equipment has the authority to change such an employment-at-will relationship."

Applicant Signature

Applicant Name

DOB

MM slash DD slash YYYY

Date

MM slash DD slash YYYY

License Information

Section 383.21 FMCSR states "No person who operations a commercial motor vehicle shall at any time have more than one driver's license." I certify that I do not have more than one motor vehicle license, the information for which is listed below.

State

License Number

Type

Expiration Date

MM slash DD slash YYYY

Driving Experience

Straight Truck

Type of Equipment (Van, Tank, Flat, etc.)

Approx Number of Miles (Total)

Date Operated From

MM slash DD slash YYYY

Date Operated To

MM slash DD slash YYYY

Tractor and Semi-Trailer

Type of Equipment (Van, Tank, Flat, etc.)

Approx Number of Miles (Total)

Date Operated From

MM slash DD slash YYYY

Date Operated To

MM slash DD slash YYYY

Tractor - Two Trailers

Type of Equipment (Van, Tank, Flat, etc.)

Approx Number of Miles (Total)

Date Operated From

MM slash DD slash YYYY

Date Operated To

MM slash DD slash YYYY

Other Equipment

Type of Equipment (Van, Tank, Flat, etc.)

Approx Number of Miles (Total)

Date Operated From

MM slash DD slash YYYY

Date Operated To

MM slash DD slash YYYY

Accident Record for Past 3 Years or More

Number of Accidents Recorded

Accident #1

Date

MM slash DD slash YYYY

Number of Fatalities

Number of Injuries

Nature of Accident (Head-on, Rear-end, Upset, etc.)

Chemical Spills

Yes

No

Accident #2

Date

MM slash DD slash YYYY

Number of Fatalities

Number of Injuries

Nature of Accident (Head-on, Rear-end, Upset, etc.)

Chemical Spills

Yes

No

Accident #3

Date

MM slash DD slash YYYY

Number of Fatalities

Number of Injuries

Nature of Accident (Head-on, Rear-end, Upset, etc.)

Chemical Spills

Yes

No

Please provide details for additional accidents:

Traffic Convictions and Forfeitures for the Past 3 Years (other than parking violations)

Number of convictions/forfeitures noted:

Conviction #1

Date Convicted

MM slash DD slash YYYY

Violation

State of Violation Location

Penalty (Forfeited Bond, Collateral and/or Points)

Conviction #2

Date Convicted

MM slash DD slash YYYY

Violation

State of Violation Location

Penalty (Forfeited Bond, Collateral and/or Points)

Conviction #3

Date Convicted

MM slash DD slash YYYY

Violation

State of Violation Location

Penalty (Forfeited Bond, Collateral and/or Points)

Please provide details for additional accidents:

License Information

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

Yes

No

If yes, please explain

Has any license, permit, or privilege ever been suspended?

Yes

No

If yes, please explain

"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: 1) Review information provided by current/previous employers; 2) Have errors in the information corrected by previous employers and for those previous employers to resend the corrected information to the prospective employer, and 3) 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."

I certify that I completed this Allegiance Crane & Equipment Employment Application Addendum, and all entries on it and information in it are true and complete to the best of my knowledge.

Applicant Signature

Application Date

MM slash DD slash YYYY

Name

This field is for validation purposes and should be left unchanged.

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