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Page 1 PARK COUNTY GOVERNMENT P.O. Box 1373, Fairplay, CO 80440 [PHONE REDACTED] (Ph) [PHONE REDACTED] (Fax) www.parkco.us [EMAIL REDACTED] Application Road & Bridge Department PRINT all information. Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. Use blank paper if you do not have enough room on this application form. You must submit a separate application for each position for which you are applying. Resumes may be included with the completed application. The applicant is required to sign and date the last page of this application. Please read carefully, sign and date the Affidavit on the last page of this application. JOB APPLIED FOR: DATE: WHEN ARE YOU AVAILABLE? PERSONAL INFORMATION Last Name: First Name: Middle Init: Phone: Current How Address: Long? Street City/State Zip Previous How Address: Long? Street City/State Zip Previous How Address: Long? Street City/State Zip Previous How Address: Long? *Required for commercial drivers MILITARY INFORMATION Active Duty Service From to Branch of Service: Service Duties: Are you a member of a Reserve organization? ---PAGE BREAK--- GENERAL INFORMATION 1. If required, are you willing to submit to a pre-employment drug test, physical exam, and background investigation? Yes No 2. Have you ever been convicted of a felony? If yes, list dates, location, and Yes No resolution of each below. 3. Have you ever applied for a position with Park County? If yes, list when and Yes No for what position: 4. Do you have any relatives currently employed by Park County? If yes, list the Yes No name(s), relationship(s), and department(s) below. 5. Have you previously worked for Park County? If yes, list when and for what Yes No position: 6. Are you now or do you expect to be engaged in any other business or employment? Yes No If yes, please explain below. 7. Have you missed any work during the past six months? If yes, please explain: Yes No Please indicate the item number above to which the following further detailed explanation applies: EDUCATION High School Diploma or GED? Yes No Where? Number of Did You Type of School School Name/Location Years Attended Graduate? Degree/Major Undergraduate: Graduate: Vocational or Technical: Other Training: Page 2 ---PAGE BREAK--- Page 3 EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address: street number, city, state, and zip code. Applicants to drive a commercial motor vehicle** in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle. List employers beginning with the most recent first. **Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 15 or more passengers or any size vehicle used to transport hazardous materials in quantity requiring placarding. Current Employer/Last Employer Name: Address: Phone No. May we contact Employer? Yes No Employed From to Contact Person: Job Title: Beginning Wage: Ending Wage: Description of Job Duties: Reason for Leaving: Previous Employer Name: Address: Phone No. May we contact Employer? Yes No Employed From to Contact Person: Job Title: Beginning Wage: Ending Wage: Description of Job Duties: Reason for Leaving: Previous Employer Name: Address: Phone No. May we contact Employer? Yes No Employed From to Contact Person: Job Title: Beginning Wage: Ending Wage: Description of Job Duties: Reason for Leaving: ---PAGE BREAK--- Page 4 ACCIDENTS OR TRAFFIC CONVICTIONS Provide accident record for the past 3 years or more (attach additional pages if more space is needed). If none, write none. Dates Nature of Accident Fatalities /Injuries Last Accident: Next Previous: Next Previous: Provide traffic convictions and forfeitures for the past 3 years (other than parking violations). If none, write none. Location Date Charge Penalty EXPERIENCE AND QUALIFICATIONS-DRIVER 1. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No 2. Has any license, permit or privilege ever been suspended or revoked? Yes No IF THE ANSWER TO QUESTION 1 OR 2 IS YES, ATTACH A STATEMENT GIVING DETAILS. Provide Driver’s License information below: State License No. Type Expiration Date Provide driving experience; if none, write none: Equipment Class Type of Equipment From To Approx. Miles Straight Truck Tractor/Semi-Trailer Tractor/Two Trailers Motor Coach/School Bus Other List states operated in for last 5 years: List special courses or training that will help you as a driver: List any safe driving awards you hold and from whom: List any trucking, transportation, or other experience that may be applicable for the position for which you are applying: List courses and training other than shown elsewhere in this application: List special equipment or technical materials you can work with, other than those already shown: ---PAGE BREAK--- Page 5 AFFIDAVIT PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer (except as previously noted), past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I have read, understand, and by my signature consent to these statements. Signature: Date: ---PAGE BREAK--- Page 6 PARK COUNTY GOVERNMENT P.O. Box 1373, Fairplay, CO 80440 [PHONE REDACTED] (Ph) [PHONE REDACTED] (Fax) www.parkco.us [EMAIL REDACTED] FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations. Applicant’s Signature Date Print Name Social Security Number ---PAGE BREAK--- Page 7 PARK COUNTY GOVERNMENT P.O. Box 1373, Fairplay, CO 80440 [PHONE REDACTED] (Ph) [PHONE REDACTED] (Fax) www.parkco.us [EMAIL REDACTED] REQUEST FOR CHECK OF DRIVING RECORD I hereby authorize you to release the following information to Park County Government for the purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information. Applicant’s Signature Date In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508 as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), I hereby certify the following : 1. The consumer (applicant) has authorized in writing the procurement of this report; 2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes; 3. The information requested below will be used for a “permissible purpose” (i.e. information for employment purposes) and will be used for no other purpose; 4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and 5. Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency. I also hereby certify the this report request and the above applicant’s release notice meet the definition of “permissible uses” of state motor vehicle records under the provisions of the Driver’s Privacy Protection Act of 1994 (Public Law 103-332, Title XXX, Section 300002(a)). Requester’s Signature Date TO: FROM: Park County, P.O. Box 1373, Fairplay, CO 80440 NAME: TITLE: SIGNED: Dear Sir or Madam: 1. The following named person has made application with Park County Government for the position of . In accordance with Section 391.23, Federal Department of Transportation Regulations, please furnish the undersigned with the applicant’s driving record for the past 3 years. 2. The following named person has made application with Park County Government for the position of . In accordance with Section 391.25, Federal Department of Transportation Regulations, please furnish the undersigned with the applicant’s driving record for the past 3 years. Name of Applicant: Date of Birth: SSN: Current Address: License No.: Former Address: ---PAGE BREAK--- Page 8 PARK COUNTY GOVERNMENT P.O. Box 1373, Fairplay, CO 80440 [PHONE REDACTED] (Ph) [PHONE REDACTED] (Fax) www.co.park.co.us [EMAIL REDACTED] REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER I hereby authorize you to release the following information to Park County Government for the purposes of investigation as required by Sections 391.23 and 383.35 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information. Applicant’s Signature Date MAIL TO: FROM: Park County, P.O. Box 1373, Fairplay, CO 80440 NAME: TITLE: SIGNED: Dear Sir or Madam: The below named individual has made application to Park County for a position as and states that he/she was employed by you as from to We appreciate your time in completing, in confidence, the information requested below. Enclosed is a business reply envelope for your convenience. Thank you for your courtesy. Name of Applicant: SSN: Dates of Employment: To Wage: Did he/she drive a motor vehicle for you? Straight Truck? Tractor-Semi-trailer? Bus? Other (specify)? Was he/she a safe driver? Was his/her general conduct satisfactory? Reason for Leaving? Discharged Resignation Lay-Off Military Duty Please advise history of past driving record if available for past three years: ---PAGE BREAK--- Page 9 CONFIDENTIAL REPORT OF PERSONAL REFERENCE Please indicate your opinion by placing a check in the appropriate column. Characteristics Excellent Good Fair Poor Disposition, Tact, Ability to get along with others Initiative, Resourcefulness Safety Habits Driving Skill Attitude Loyalty Any other remarks: Signature: Title: Date: