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Employment Application

Roberts Trucking [logo]
5501 Route 89, North East, PA 16428

We are an Equal Opportunity Employer

(*) Denotes required fields.
Printable Application
Click here for a blank, printable application to fill out by hand and mail in.

SSL Secure Form Date*

Applicant Information

Name* 
  Last First Middle

Phone Number*  E-mail 

Address*
Street City State Zip

Are you legally authorized to work in the U.S.?* Yes   No
If hired, you will be required to provide proof of work authorization.

Are you at least 18 years old?* Yes   No
If not, your employment will be subject to verification that you meet state/federal minimum age requirements for the type of work you are applying for and have obtained a valid work permit.

Have you ever pleaded "guilty" or "no contest" or been convicted of a crime?* Yes   No
If yes, please explain 1) nature of crime, 2) date of conviction, and 3) state and county in which convicted in the space provided.
(A conviction will not necessarily bar you from employment. You should not disclose any information regarding criminal records that have been sealed.)

Have you ever applied at this company before?* Yes   No
When?*   
  Month Year  

Have you ever worked at this company before?* Yes   No
From*  To*  Under what name? 
  Month Year   Month Year  

Will you travel if job requires it?* Yes   No

Will you work overtime if required?* Yes   No

If they have been explained to you, are you able to meet the attendance requirements of the position?* N/A   Yes   No

Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)?*
This question is not designed to elicit information about an applicant's disability. Issues regarding the existence of a disability, particular accommodation, or whether accommodation is necessary may be addressed at a later stage to the extent permitted by law.
Yes   No   Need more information about the job's "essential functions" to respond

Position Applying For

Name of Position* Part-Time or Full-Time Desired*
Desired Compensation* Shift Preference* 1st 2nd 3rd
When can you start?*
Who referred you?
How did you hear about us?*
Agency  Walk-in  Internet  Newspaper  School  Friend/Relative 
Other 

Special Skills

1. If relevant, please describe word-processing speed, software knowledge, and office equipment experience:

2. If relevant, please describe experience using manufacturing machines and equipment:

3. Please list other valuable skills you possess that would be valuable to the company:

Education*

High School
No. Years Attended 
Name City State  
Diploma or Degree Received Yes   No  
Major Subjects    
High School (2)
No. Years Attended 
Name City State  
Diploma or Degree Received Yes   No  
Major Subjects    

College
No. Years Attended 
Name City State  
Diploma or Degree Received Yes   No
Type: 
Major Subjects    
College (2)
No. Years Attended 
Name City State  
Diploma or Degree Received Yes   No
Type: 
Major Subjects    

Graduate
No. Years Attended 
Name City State  
Diploma or Degree Received Yes   No
Type: 
Major Subjects    
Graduate (2)
No. Years Attended 
Name City State  
Diploma or Degree Received Yes   No
Type: 
Major Subjects    

Other
No. Years Attended 
Name City State  
Diploma or Degree Received Yes   No
Type: 
Major Subjects    
Other (2)
No. Years Attended 
Name City State  
Diploma or Degree Received Yes   No
Type: 
Major Subjects    

Training Courses

List any relevant training programs completed.

Course/Seminar Sponsoring Organization Content Date Attended

Required License(s)

If required to drive a motor vehicle for the job applying for, state your:
Driver's License Number State Issued Expiration Date
Registration or Plate Number State Issued Expiration Date
Are you licensed/have certifications which will assist in the job? Yes   No
Please explain.

Employment History

(Start with most recent.)

Employer*
Name Address City State Zip
From*  To*  Compensation Start*   End 
  Month Year   Month Year  
Job Title*      Immediate Supervisor* 
Telephone*  Reason for leaving*       
Description of Duties*
If currently employed, may we contact as a reference?*  Yes   No   Later

Employer*
Name Address City State Zip
From*  To*  Compensation Start*   End 
  Month Year   Month Year  
Job Title*      Immediate Supervisor* 
Telephone*  Reason for leaving*       
Description of Duties*

Employer*
Name Address City State Zip
From*  To*  Compensation Start*   End 
  Month Year   Month Year  
Job Title*      Immediate Supervisor* 
Telephone*  Reason for leaving*       
Description of Duties*

Employer*
Name Address City State Zip
From*  To*  Compensation Start*   End 
  Month Year   Month Year  
Job Title*      Immediate Supervisor* 
Telephone*  Reason for leaving*       
Description of Duties*

Employer*
Name Address City State Zip
From*  To*  Compensation Start*   End 
  Month Year   Month Year  
Job Title*      Immediate Supervisor* 
Telephone*  Reason for leaving*       
Description of Duties*

Employer*
Name Address City State Zip
From*  To*  Compensation Start*   End 
  Month Year   Month Year  
Job Title*      Immediate Supervisor* 
Telephone*  Reason for leaving*       
Description of Duties*

Employment References*

Name Address City State Zip
Day Telephone*       Relationship*           
Evening Telephone  How long known?* 

Name Address City State Zip
Day Telephone*       Relationship*           
Evening Telephone  How long known?* 

Name Address City State Zip
Day Telephone*       Relationship*           
Evening Telephone  How long known?* 

Please Read Carefully Before Signing This Form

  1. All information contained in this application is true and correct to the best of my knowledge and belief. I understand that misrepresentations or omissions of any kind may result in denial of employment or be cause for subsequent dismissal if I am hired, regardless of when such information is discovered.
  2. I authorize the company to investigate my responses on this application and contact any or all of my former employers or any individuals familiar with me or my employment background for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me or my employment. I voluntarily and knowingly fully release and hold harmless any persons or organizations providing information pertaining to me or my employment.
  3. I understand that upon receiving a job offer, a physical examination and drug screening may be required. (Note: If this is a job requirement, you will be notified.)
  4. I understand that prior to my employment I may be asked to sign a background check consent form or other documentation in order to facilitate my hiring. I agree to sign these forms.
  5. I understand that this application remains current for only 90 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.
  6. This company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under the applicable federal, state or local law. The company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, age, disability or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate or non-employee (such as a vendor or customer). The company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.
  7. Regardless of whether or not I become employed by the company, I recognize that this application is not and should not be considered a contract of employment. I understand that employment at the company is on an at-will basis and that my employment may be terminated with or without cause, and without notice, at any time, at my option or the company’s, unless specifically provided otherwise in a written employment contract. I further understand that no company employee or representative has the authority to enter into a contract regarding duration or terms and conditions of employment other than an officer or official of the company, and then only by means of a signed, written document.
Name* Date*

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