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BREMIK,LLC - APPLICATION FOR EMPLOYMENT
1015 Wittkopf Lane - Algona, Iowa

(First) (Middle) (Maiden, If Any) (Last)
Address *
Address
IF SAME AS CURRENT ADDRESS LEAVE BLANK (Street) (City) (State & Zip Code) (#Yrs)
Section 38321 FMCSR states “No person who operates a commercial motor vehicle shall at anytime have more than one drivers license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.
License Exp. Date *
License Exp. Date
(Van, Tank, Flat, Etc.)
Date (Starting) *
Date (Starting)
Date (Ending)
Date (Ending)
(Van, Tank, Flat, Etc.)
Date (Starting)
Date (Starting)
Date (Ending)
Date (Ending)
(Van, Tank, Flat, Etc.)
Date (Starting)
Date (Starting)
Date (Ending)
Date (Ending)
(Van, Tank, Flat, Etc.)
Date (Starting)
Date (Starting)
Date (Ending)
Date (Ending)
(Nature of Accident; Head-On, Rear-End, Upset, Etc.)
Date
Date
(Nature of Accident; Head-On, Rear-End, Upset, Etc.)
Date
Date
(Nature of Accident; Head-On, Rear-End, Upset, Etc.)
Date
Date
(We Ask That You Provide Us With All Accident Information From The Past Three Years or More)
1. Traffic Convictions & Forfeitures
1. Traffic Convictions & Forfeitures
(Other Than Parking Tickets)
(Forfeited Bond, Collateral And/Or Points)
2. Traffic Convictions & Forfeitures
2. Traffic Convictions & Forfeitures
(Other Than Parking Tickets)
(Forfeited Bond, Collateral And/Or Points)
3. Traffic Convictions & Forfeitures
3. Traffic Convictions & Forfeitures
(Other Than Parking Tickets)
(Forfeited Bond, Collateral And/Or Points)
(We Ask That You Provide Us With All Conviction & Forfeiture Information From The Past Three Years or More)

EMPLOYMENT RECORD

Name *
Name
Address *
Address
Phone *
Phone
Date (Start) *
Date (Start)
Date (End)
Date (End)
$
Address
Address
Phone
Phone
Date (Start)
Date (Start)
Date (End)
Date (End)
$
Address
Address
Phone
Phone
Date (Start)
Date (Start)
Date (End)
Date (End)
$
To Be Read & Signed By Applicant *
To Be Read & Signed By Applicant
I authorize you to make investigations and inquiries to 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 BREMIK, LLC. "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 information corrected by previous employers and for those previous employers to re-send the correct 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." TERMS OF ACCEPTANCE and SIGNATURE I, the applicant, for this position in employment, warrant the truthfulness of the information provided in this application.
Date *
Date
Acknowledgement of Legal Signature *
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
Completion of Application *
Completion of Application
This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.
Date *
Date
Acknowledgement of Legal Signature *
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.