Join Our Team — BREMIK, LLC

BREMIK, LLC

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

Name

(First) (Middle) (Maiden, If Any) (Last)

Email Address

Phone 1

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How Long Have You Been A Resident At Your Current Residence?

Previous Three Years Residency

IF SAME AS CURRENT ADDRESS LEAVE BLANK (Street) (City) (State & Zip Code) (#Yrs)

Drivers License Number

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.

Issuing State of License

License Type

License Exp. Date

YYYY

1. Driving Experience

Type Of Equipment

(Van, Tank, Flat, Etc.)

Date (Starting)

YYYY

Date (Ending)

YYYY

2. Driving Experience

Type Of Equipment

(Van, Tank, Flat, Etc.)

Date (Starting)

YYYY

Date (Ending)

YYYY

3. Driving Experience

Type Of Equipment

(Van, Tank, Flat, Etc.)

Date (Starting)

YYYY

Date (Ending)

YYYY

4. Driving Experience

Type Of Equipment

(Van, Tank, Flat, Etc.)

Date (Starting)

YYYY

Date (Ending)

YYYY

Additional Driving Experience

1. Accident Record

(Nature of Accident; Head-On, Rear-End, Upset, Etc.)

Date

YYYY

Number of Fatalities

Number of Injuries

Chemical Spills

2. Accident Record

(Nature of Accident; Head-On, Rear-End, Upset, Etc.)

Date

YYYY

Number of Fatalities

Number of Injuries

Chemical Spills

3. Accident Record

(Nature of Accident; Head-On, Rear-End, Upset, Etc.)

Date

YYYY

Number of Fatalities

Number of Injuries

Chemical Spills

Additional Accident Report Information

(We Ask That You Provide Us With All Accident Information From The Past Three Years or More)

1. Traffic Convictions & Forfeitures

(Other Than Parking Tickets)

YYYY

Violation

State of Violation Location

Penalty

(Forfeited Bond, Collateral And/Or Points)

2. Traffic Convictions & Forfeitures

(Other Than Parking Tickets)

YYYY

Violation

State of Violation Location

Penalty

(Forfeited Bond, Collateral And/Or Points)

3. Traffic Convictions & Forfeitures

(Other Than Parking Tickets)

YYYY

Violation

State of Violation

Penalty

(Forfeited Bond, Collateral And/Or Points)

Additional Convictions & Forfeitures Information

(We Ask That You Provide Us With All Conviction & Forfeiture Information From The Past Three Years or More)

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

If yes, explain (If no, enter "N/A"):

Has any license, permit or privilege ever been suspended or revoked?

If yes, explain (If no, enter "N/A"):

EMPLOYMENT RECORD

Name

First Name

Last Name

Last Employer

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Position Held

Date (Start)

YYYY

Date (End)

YYYY

Salary

Reason For Leaving

Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49CFR part 40?

Second Last Employer

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Position Held

Date (Start)

YYYY

Date (End)

YYYY

Salary

Reason for Leaving

Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49CFR part 40?

Third Last Employer

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Position Held

Date (Start)

YYYY

Date (End)

YYYY

Salary

Reason for Leaving

Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49CFR part 40?

Additional Employment Information

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.

First Name

Last Name

Date

YYYY

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

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.

First Name

Last Name

Date

YYYY

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.

“LIFE’S SHORT, PUMP HARD”