BFL Application Form

BFL, Inc.
1883 South State Road 161
Rockport, IN 47635
Office (812) 649-9103

Date of Application

Personal Information :

Position(s) Applied For: E-mail:

First Name: Last Name: Middle Initial:

Social Security#:

Address: City:

State: Zip Code: Phone:

Do you have the legal right to work in the United States?

Date of Birth? (required for Commercial Drivers)

Can you provide proof of age? Yes No

Previous Work Information
Have you worked for this company before? Where?

Dates (From): To:

Rate of Pay: Position:

Reason For Leaving?

Are you now employed? Yes No

If not, how long since leaving last employment?

Who referred you? Rate of pay expected?

Is there any reason you might be unable to perform the functions of the job for which you have applied
(as described in the attached job description )?

If yes, explain if you wish:

Accident record for past 3 years or more. (Start with most recent account)
CLICK HERE IF NONE:

DATES	NATURE OF ACCIDENT (head-on, rear-end, upset, etc.)	FATALITIES	INJURIES

Traffic Convictions and forfeitures for the past 3 years (other than parking violations).
CLICK HERE IF NONE

LOCATION	DATE	CHARGE	PENALTY

Education

Select Highest Grade Completed:
Grammar School: 1 2 3 4 5 6 7 8
High School: 1 2 3 4
College: 1 2 3 4

Name of last school attended: City:

Experience and Qualifications - Driver
DRIVERS LICENSES:

STATE	LICENSE NO.	TYPE	EXP. DATE

A.) Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No

B.) Has any license, permit or privilage ever been suspended or revoked? Yes No

If the answer to either A or B is YES, please explain why below:

DRIVING EXPERIENCE :
CLICK HERE IF NONE

CLASS OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	TYPE OF EQUIPMENT	DATES		APPROX. NO. OF MILES
CLASS OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	TYPE OF EQUIPMENT	TO	FROM:	(TOTAL)
STRAIGHT TRUCK
TRACTOR & SEMI-TRAILER
TRACTOR-TWO TRAILERS
MOTOR COACH - SCHOOL BUS
OTHER

List States operated in for last five years:

Show special courses or training that will help you as a driver:

Which safe driving awards do you hold and from whom?

Experience and Qualifications - Other

Show any trucking, transportation or other experience that may help in your work for this company:

List courses and training other than shown elsewhere in this application:

List special equipment or technical materials you can work with (other than those already shown)

TERMS AND AGREEMENT - TO BE READ AND SIGNED BY APPLICANT

This certifies 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 authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

Yes, I agree to the terms stated above

Date Applicant's Signature

Process Record
Applicant Hired: Rejected:

Date Employed : Point Employed :

Department: Classification:
(If rejected, summary report of reasons should be placed in file).

Transfers
From: To: Date:

Reason For Transfer:

From: To: Date:

Reason For Transfer:

Termination of Employment
Date Terminated: Department Released From:

Dismissed: Voluntarily Quit:

Other:

Termination Report Placed in File: Supervisor:

Employment History All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. )

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

* Includes vehicles having a GVWR of 26,991 lbs, or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

Safety Performance History Records Request
(TO BE COMPLETED BY PROSPECTIVE EMPLOYEE)

I,
(First, M.I., Last)	Social Security Number	Date of Birth


HEREBY AUTHORIZE:

Previous Employer: E-Mail:

Street: City:

State: Zip:

Telephone: Fax:

to release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from

(date of employment application)

TO:
Prospective Employer:	BFL, INC
Attention:	Safety
Telephone:	866-235-0873
Street:	Rockport, IN. 47635

In compliance with §40.25(g) and §391.23 (h), release of this information must be made in a written form that ensures confidentiality.

Prospective employer's confidential fax number:

Prospective employer's confidential email address:


Applicant's Signature	Date

This information is being requested in compliance with §40.25 and §391.23

MOTOR VEHICLE REPORT AUTHORIZATION
CLICK HERE TO DOWNLOAD MOTOR VEHICLE REPORT AUTHORIZATION FORM (required).
Please complete form, sign and fax to (270)-689-1292
Attention: Teresa Sauter
Subject: Motor Vehicle Report Authorization