GENERAL INFORMATION (Please fill out completely or insert “N/A” (Not Applicable)

List your addresses for the past 3 years
Have you been employed at NEBS before?
Work Type
If necessary, can you work evenings and/or weekends?
How did you find out about employment opportunities at NEBS?
Can you produce documents to show you are legally eligible to work in the U.S.? (NOTE: any offer of employment is conditioned upon completing form I-9 and providing appropriate documentation)
Are you able to perform the essential function(s) of the job(s) applied for either with or without an accommodation?

EDUCATION
Do you plan to further your education?
EMPLOYMENT HISTORY
Must be filled out completely, please list most recent employment first. Applicants for the position of driver must show all employment for the past three years and show commercial driving employment for a seven-year period preceding the three years. 

May we contact this employer:
Were you subject to the Federal Motor Carrier Safety Regulations while employed?
Was your job designated as a safety-sensitive function in any DOT-related mode subject to the drug & alcohol testing requirements of 49 CFR Part 40?one
Employer 2
May we contact this employer:
Were you subject to the Federal Motor Carrier Safety Regulations while employed?
Was your job designated as a safety-sensitive function in any DOT-related mode subject to the drug & alcohol testing requirements of 49 CFR Part 40?one
Employer 3

May we contact this employer:
Were you subject to the Federal Motor Carrier Safety Regulations while employed?
Was your job designated as a safety-sensitive function in any DOT-related mode subject to the drug & alcohol testing requirements of 49 CFR Part 40?one
Professional References

CERTIFICATION AND AGREEMENT


This certifies 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 understand that falsification or incompleteness of this information may result in my not being considered for employment or dismissal if I am employed. I authorize the references, former employers and educational institutions listed on this application to give you any and all information concerning my previous employment and/or education achieved they may have, personal or otherwise, and release all parties from all liability for any damages that may result from furnishing any lawful job-related information. I understand that before any offer of employment is extended and/or before actual employment commences, I may be required to submit to a background check as required by the Company. I may also be required to submit to blood, urine, and/or other medical testing for detection of alcohol, drugs, and/or other controlled substances in accordance with Company policies post-offer. Additionally, I may be required by the Company to submit to a post-offer physical examination. Unsatisfactory or inconclusive results of the post-offer examination may necessitate withdrawal of the job offer.

If I am a candidate for a position involving the operation of a commercial motor vehicle, I hereby acknowledge that I have been made aware that the informationI have provided with respect to my previous employers may be used, and my previous employers may be contacted, for the purpose of investigating my background as required by 49 CFR §391.23. I understand as a condition of employment, I will be required to show identification which proves my legal right to work in the United States. If employed, I agree to follow the rules, regulations and other directives of the Company. However, I understand that my employment is "at-will" and can be terminated, with or without cause, and with or without notice, at any time, at the option of either the Company or myself. I understand that no Company representative other than the ChiefExecutive Officer (CEO), has any authority to enter into any agreement to employ me for any specific period of time, or to make any agreement contrary to the foregoing. Any contrary agreement by the CEO must be in writing, signed and dated. I acknowledge that no other representatives have been made to me as of this date concerning employment by the Company. I have carefully read and understood the above, and hereby consent and agree to these conditions in exchange for the Company’s consideration of my application for employment.

49CFR §391.23(d) and (e). I understand that I have the right to:

  • Review information provided by current/previous employers;
  • Have errors in the information corrected by the previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
  •  Have a rebuttal statement attachment to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

WE PARTICIPATE INE-VERIFY

NOTICE:Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. This SecurityWork Authorization (SWA) will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each applicant’s Form I-9 to confirm work authorization. IMPORTANT: If theGovernment cannot confirm that you are authorized to work, this SWA is required to provide you written instructions and an opportunity to contact SSA and/orDHS before taking adverse action against you, including terminating your employment SWA and employers may not use E-Verify to re-verify current employees and may not limit or influence the choice of documents presented for use on the Form I-9.  If you believe that your SWA has violated its responsibilities under this program or has discriminated against you during the verification process based upon your national origin or citizenship status, please call the Office of SpecialCounsel for Immigration Related Unfair Employment Practices at 1-800-255-7688(TDD: 1-800-237-2515).