Please fill out the form and print it.  Then fax it to the appropriate plant.
After faxing this document, please phone the facility you have faxed to
 
APPLICANT INFORMATION
Last Name First Name  M.I. Date
Street Address Apartment/Unit#
City State   Zip Desired Salary
Phone Email  
Date Available Social Security Position Applied For
Are you a citizen of the US Yes No  If no, are you authorized to work in the US Yes No
Have you ever worked for this company Yes No   If so, when?
Have you ever been convicted of a felony? Yes No   Explain?
 
LICENSE INFORMATION
Driver's License# State   Exp. Date

License Type(CDL, Class A, Class 1, etc)

CDL Endorsements Has your license, permit, or privilege been suspended or revoked Yes No
Have you ever been denied a permit, license, or privilege to operate a motor vehicleYes No
If yes, please explain
 
DRIVING EXPERIENCE
Type of Vehicle Number of Years Experience State in which vehicle was operated
Do you have full knowledge of the Federal Motor Carrier Safety Regulations?Yes No
 
ACCIDENT RECORD LAST THREE YEARS
Date Nature of Accident No. of Fatalities No. of Injuries Commercial Value Personal Automobile
 

 

 
TRAFFIC CONVICTIONS AND FORFEITURES LAST THREE YEARS (OTHER THAN PARKING)
State Date Charge Penalty Commercial Value or Personal Automobile
 
EDUCATION
High School   Address
From To Did you Graduate Yes No    
College   Address
From To Did you Graduate Yes No Degree
Other   Address
From To Did you Graduate Yes No Degree
 
REFERENCES
Please list three professional references.
Full Name Company Relationship
Address Phone
Full Name Company Relationship
Address Phone
Full Name Company Relationship
Address Phone
 
PREVIOUS EMPLOYMENT
Company Phone Supervisor
Job Title Starting Salary $ Ending Salary $
Responsibilities From To
Reason for Leaving
Company Phone Supervisor
Job Title Starting Salary $ Ending Salary $
Responsibilities From To
 

 
MILITARY SERVICE
Branch From To Rank at Discharge
Type of Discharge If other than honorable, explain
 
DISCLAIMER
I certify that my answers are true true and complete to the best of my knowledge.  I understand that any misrepresentation of information given above shall be considered an act of falsification.  I agree that Centre Concrete may investigate my background to ascertain that all information listed above is factual.  If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.  I agree and understand that if hired, I will be on a probationary period during which time I may be discharged without recourse.
 
FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
In accordance with the provisions of Section 604(b)(2)(A); 606 and 615 of the Fair Credit Reporting Act, effective September 30, 1997 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.  Note:  In accordance with DOT regulations for appropriate drivers these reports are required by Section 382.413.391.23, and 391.25 of the Federal Motor Carriers Safety Regulations.

I also understand that my employer will periodically review my Motor Vehicle Record to determine continued eligibility to drive a company vehicle.  This authorization is valid as long as I am an employee and may only be rescinded in writing.
Signature: Full Name Date
   
Please fill out the job application and fax it to the plant that you are submitting the application to.
 
State College Montoursville Lock Haven Big Flats, NY Woodland
Plant Phone: 
1-814-238-2471

Fax: 
1-814-238-2914

 Plant Phone: 
1-570-433-3186

Fax: 
1-570-433-4408

 Plant Phone: 
 1-570-748-7747

Fax: 
1-570-748-5777

 Plant Phone: 
1-607-562-3301

Fax: 
1-607-562-3011

 Plant Phone: 
1-814-857-7690

Fax: 
1-814-857-7692