HYDROVAC OPERATOR APPLICATION Step 1 of 7 14% APPLICANT NAMEPHONE(Required)CURRENT ADDRESS Street Address City State / Province / Region ZIP / Postal Code HOW LONG HAVE YOU LIVED AT YOUR CURRENT ADDRESS(YR. / MO.)PREVIOUS ADDRESS 1 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HOW LONG DID YOU LIVE AT PREVIOUS ADDRESS 1(YR. / MO.)PREVIOUS ADDRESS 2 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HOW LONG DID YOU LIVE AT PREVIOUS ADDRESS 2(YR. / MO.)DO YOU HAVE A LEGAL RIGHT TO WORK IN THE UNITED STATES OF AMERICA? YES NO DATE OF BIRTH MM slash DD slash YYYY HAVE YOU BEEN EMPLOYED BY BULLY INDUSTRIAL BEFORE? YES NO WHERE?DATESExample: Jan 2020 to July 2020PAY-RATEPOSITIONREASON FOR SEPARATIONARE YOU CURRENTLY EMPLOYED? YES NO HOW LONG SINCE LAST EMPLOYMENT?HOW DID YOU HEAR ABOUT BULLY?EXPECTED PAY-RATE?ANY REASON YOU MIGHT BE UNABLE TO PERFORM THE FUNCTIONS OF THE JOB FOR WHICH YOU HAVE APPLIED? YES NO IF YES, EXPLAIN IF YOU WISH EMPLOYMENT HISTORYAll interstate commerce driver applicants must provide the following information on all employers during the preceding 3 years: Mailing address, street number, city, state and zip code. All commercial motor vehicle driver applicants, intrastate or interstate commerce, shall also provide an additional 7 years for the employers whom the applicate operated such vehicle.EMPLOYER NAMESTART DATE MM slash DD slash YYYY END DATE MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code POSITIONSALARY / WAGECONTACT PERSONREASON FOR LEAVINGWERE YOU SUBJECT TO FMCSRS WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTIONING ANY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUIREMENTS OF 40 CFR PART 40? YES NO EMPLOYER NAMESTART DATE MM slash DD slash YYYY END DATE MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code POSITIONSALARY / WAGECONTACT PERSONREASON FOR LEAVINGWERE YOU SUBJECT TO FMCSRS WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTIONING ANY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUIREMENTS OF 40 CFR PART 40? YES NO EMPLOYER NAMESTART DATE MM slash DD slash YYYY END DATE MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code POSITIONSALARY / WAGECONTACT PERSONREASON FOR LEAVINGWERE YOU SUBJECT TO FMCSRS WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTIONING ANY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUIREMENTS OF 40 CFR PART 40? YES NO DRIVER EXPERIENCEACCIDENT RECORDFor the past 3 years or more. Click the plus sign to add additional rows as needed.DateNature of AccidentFatalitiesInjuriesHazardous Material Spill Add RemoveTRAFFIC CONVICTIONSand forfeitures for the past 3 yrs. (other than parking violations). Click the plus sign to add additional rows.LocationDateChargePenalty Add RemoveDRIVER EXPERIENCE & QUALIFICATIONS(Required)StateLicense No.ClassEndorsementExpiration Date Add RemoveHAVE 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 IF THE ANSWER WAS YES TO EITHER QUESTION A OR B, PLEASE PROVIDE DETAILS: DRIVER EXPERIENCESTRAIGHT TRUCK YES NO EQUIPMENT TYPE VAN TANK DUMP REFER DATESFROM M/Y - TO M/YAPPROX. NUMBER OF MILESTRACTOR & SEMI-TRAILER YES NO EQUIPMENT TYPE VAN TANK DUMP REFER DATESFROM M/Y - TO M/YAPPROX. NUMBER OF MILESTRACTOR - TWO TRAILERS YES NO EQUIPMENT TYPE VAN TANK DUMP REFER DATESFROM M/Y - TO M/YAPPROX. NUMBER OF MILESTRACTOR - THREE TRAILERS YES NO EQUIPMENT TYPE VAN TANK DUMP REFER DATESFROM M/Y - TO M/YAPPROX. NUMBER OF MILESMotor Coach - School BussMore than 8 passengers YES NO EQUIPMENT TYPE VAN TANK DUMP REFER DATESFROM M/Y - TO M/YAPPROX. NUMBER OF MILESMotor Coach - School BussMore than 15 passengers YES NO EQUIPMENT TYPE VAN TANK DUMP REFER DATESFROM M/Y - TO M/YAPPROX. NUMBER OF MILES LIST ALL STATES OPERATED IN FOR THE LAST 5 YEARSclick the plus button to add more lines Add RemoveEXPERIENCE & QUALIFICATIONS – OTHERPLEASE LIST ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN WORK FOR THIS COMPANY:LIST ALL COURSES AND TRAINING OTHER THAN WRITTEN ELSEWHERE IN THE APPLICATION:click the plus button to add more lines Add RemoveLIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN ALREADY SHOWN)click the plus button to add more lines Add RemoveEDUCATIONHIGHEST GRADE COMPLETED 1 2 3 4 5 6 7 8 HIGH SCHOOL 1 2 3 4 COLLEGE 1 2 3 4 LAST SCHOOL ATTENDEDCITY | STATE * In compliance with State and Federal equal opportunity employment laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.CERTIFICATION(Required) I certify 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. I hereby release employers’, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with this application. I understand that information that 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 in accordance to 49 CFR 391.23(d) & (e). I understand that have to: Review information by previous employers; Have errors in the information corrected by previous employers and those previous employers to re-send the corrected information; and Have a rebuttal statement attached to the alleged erroneous information, if the previous employers and I cannot agree on the information.DIGITAL SIGNATUREPlease type your name to sign.Upload ResuméOptionalMax. file size: 256 MB.CommentsThis field is for validation purposes and should be left unchanged.
