Safety Trainer

Instructions: Please list your employer(s) for the past three years, listing the most recent employer first. Any gaps in employment and/or unemployment must be explained. If additional space is required, please enter on a separate sheet.
* CDL Drivers: Please list your employers for the past ten years, listing the most recent employer first.
When answering questions A and B, please refer to the following information.
* The Federal Motor Carrier Safety Regulations (FMCSR’s) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

If you did not provide work references in your employment history, please provide a reference who has knowledge of your occupational skills and background.

An Equal Opportunity Employer
HL Chapman and/or affiliates, provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, HL Chapman and/or affiliates complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities.

Please read the following statement before signing.
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 current/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.”

I understand that the hiring process may require interviews, written tests and job demonstrations. I agree that I will state whether I need any reasonable accommodations for the job selection procedures.

I understand and agree that I will participate in a Drug and Alcohol test and a physical examination if a job offer is made and that my employment is contingent on satisfactory completion of the test and the examination.

Furthermore, I understand that misrepresentation or omission of requested information may result in my disqualification of employment or dismissal from employment process.

This application is not an employment contract. Any offer of employment will be on an employment-at-will-basis. This means that I will not have an express or implied employment contract and that both the employer and I will have the right to terminate my employment at any time and for any reason.

My signature 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.

We are Equal Opportunity Employer. As required by law, we must record certain information as part of our Affirmative Action Program. Applicants for employment are invited to complete this informational form. You are advised that (a) you are under no obligation to respond but may do so in the future, (b) responses will remain confidential, and (c) responses are only used to provide necessary information included in Affirmative Action reporting. Refusal to provide this i1?formation will have no effect on your application.for employment.

Please check all that apply