First Name: M.I.:
Last Name:
Email:          Date:
Address:    
Apt./Unit:   
City:             State:   Zip:
Phone:           
Date Available:
Desired Salary:
Position Applied for:
How did you hear about us?
Who referred you to us?
Are you a citizen of the U.S.?  YesNo
If no, are you authorized to work in the U.S.?  YesNo
Have you ever worked for this company?  Yes No
If so, when?:
Have you ever been convicted of a felony?   Yes   No
If yes, explain:

Education

High School:
Address:
From: To:
Did you graduate?  Yes  No
Degree:

Driver's Licenses

State of License: License No.:
Class:
Endorsement(s):
Expiration Date:

State of License: License No.:
Class:
Endorsement(s):
Expiration Date:

State of License: License No.:
Class:
Endorsement(s):
Expiration Date:

Accident Review for Past 3 Years

Last Accident:

Date:
Nature of Accident

Fatalities

Injuries

Next Previous Accident:

Date:
Nature of Accident

Fatalities

Injuries

Next Previous Accident:

Date:
Nature of Accident

Fatalities

Injuries

If additional accidents, pleae provide details below:

Traffic convictions and forefeitures for the past 3 years other than parking violations (please provide information including location, date, charge, and penalty):

Driver Experience and Qualification

Current Driver's License Number:
Do you have, or have you ever held, a commercial driver's license?
  Yes   No
If yes, complete the following. If no, skip the next session.
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
  Yes   No
Has any license, permit, or privilege ever been suspended or revoked?
  Yes   No
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?   Yes   No
If you answered “ yes” to any of the above questions, please explain:

References

Please list three professional references, including full name, relationship, company, address and phone.

Reference 1 Reference 2 Reference 3

Military Service

Branch: From: To:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:

Previous Employment

Company 1
Name of Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities
From: To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes No

Company 2
Name of Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities
From: To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes No

Company 3
Name of Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities
From: To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes No

Please add any additional information here:

United Communications Group Inc. Job Functions

All United Communications Group field employees must be able to perform the following essential functions with or without reasonable accommodation. United Communications Group is an equal opportunity employer with every intention of making reasonable accommodation to the handicapped in accordance with the American and Disabilities Act (ADA).

The following factors constitute essential functions for any field employee of United Communications Group. (This is not a job description)

1.  I am able, with reasonable accommodation if necessary, to perform all of the following essential job functions.  Yes No
2. I am able to read, speak, understand, and write the English language at least to the 8th grade level.  Yes No
3.  I am able to perform mathematical calculations at the 8th grade level in order to perform any addition, subtraction, multiplication, and division problems used in reporting or calculating rigging capacities. Yes No
4. I can read and understand basic instruction sheets and manuals.
Yes No
5.  I am able to lift up to 75 pounds.  Yes No
6. I am willing to work out of town 6 weeks at a time.  Yes No

If you answered “No” to any of the job functions listed above, please explain:

Applicants will not necessarily be disqualified if they are unable to perform a specific function.

Applicant must read the following important notice:

United Communications Group is an equal opportunity and “at will” employer.  All applicants for employment will be considered without regard to race, color, religion, sex national origin, disability, or age.           

I understand my employment with United Communications Group is far no definite length of time and may be terminated at any time, with or without cause, at the option of either United Communications Group or myself.  I understand that no associate or representative of United Communications Group has any authority to make any agreement which is contrary to the foregoing.

I certify that I have read and understood all of this employment application.  It is agreed and understood that the employer is his agents may investigate my background to ascertain any and all information concerned to my employment history, whether same is of record or not, and I release employers and other persons named herein from all liability for any damages on account of furnishing such information.  I understand that as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job.  I also understand that if offered a job, it may be conditioned on the results of a physical examination and a drug test.

It is agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508; I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.  It is also agreed that under Department of Transportation section 382.413, I hereby authorize the company to obtain a driver motor vehicle report, drug screening, and a Department of Transportation physical examination.

I agree to furnish such additional information and complete such examinations as my be required to complete my employment file.

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of the employer.

By clicking on the following "Submit" button, I am certifying that this application was completed by me, and that all the entries on it and information in it are true and complete to the best of my knowledge. This will also be equivalant to a digital signature.