BEAM
BROS.
TRUCKING
INC
SPECIALIZED TRUCKING SERVICE
(540) 434-8545
P O BOX 183
MT CRAWFORD, VA 22841
1-800-824-2846
FAX (540) 282-5442
WHEN SUBMITTING A COMPLETED
(Non Driver) APPLICATION PLEASE
REMEMBER TO ENCLOSE A COPY OF
THE FOLLOWING:
 Completed Non Driver Application
 Resume
 Salary/Pay Requirements
Email: [email protected]
Fax: 540-282-5442
Mail: P.O. Box 183
Mt. Crawford, VA 22841
(Attn: Recruiting)
BEAM BROS. TRUCKING, INC.
P.O. Box 183
Mt. Crawford, VA 22841
540-434-8545 Fax 540-282-5442
APPLICATION
FOR EMPLOYMENT
Applicant Name____________________________________________________________Date____________________
In compliance with Federal and State Equal Employment Opportunity Laws, prospective applicants will receive consideration for all positions without regard to race, color, sex, age, religion, marital status, veteran status, disability, national origin, or any other prohibited basis of discrimination. Applicant: We appreciate your interest in Beam Bros. Trucking, Inc., also referred to as the Company, and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications and may assist us in possible future considerations. If you meet the Company’s requirements, we will conduct an in‐depth review of your background, experience and safety record. If you qualify, you will be scheduled for an interview, road test and drug test. Questions on this application are required by Beam Bros. Trucking, Inc. Therefore, before any applicant can be considered for employment, this application must be completed in its entirety. APPLICANT’S STATEMENT ‐ TO BE READ AND SIGNED BY APPLICANT The following statements and answers are true and complete to the best of my knowledge. I authorize you to make such investigation and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. I understand that any false or misleading information or omission provided during the application or interview process will result in my immediate discharge if I am hired, regardless of when discovered. Also, that I am required to abide by all the rules and regulations of the Company. I understand that until all background information and driver qualification requirements have been verified by the Company or its agents, any offer of employment made is conditional. This means that an offer of employment may be withdrawn if the applicant does not meet the Company or Government qualification requirements. I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT OF EMPLOYMENT. I ALSO UNDERSTAND THAT IF HIRED, REGARDLESS OF ANY ORAL REPRESENTATIONS TO THE CONTRARY, THE EMPLOYMENT RELATIONSHIP BETWEEN MYSELF AND THE COMPANY IS TERMINABLE‐AT‐WILL SO THAT BOTH THE COMPANY AND I REMAIN FREE TO CHOOSE TO END OUR WORK RELATIONSHIP AT ANY TIME FOR ANY OR NO REASON. ANY CHANGES IN THIS EMPLOYMENT RELATIONSHIP MUST BE MADE IN WRITING AND WITHIN THE GUIDELINES OUTLINED IN THE COMPANY POLICY HANDBOOK. I understand a drug or alcohol test may be required depending upon the Company policy. I authorize the Company to make a thorough investigation of my past employment, education and job‐related activities and I release from all liability all persons, companies, and corporations supplying such information. I also indemnify this Company and its' employees against liability which might result from making such investigation. My signature certifies that the above statements were read, understood, and agreed upon by me. Signature___________________________________________________________________Date_____________________________ Applicant Hired______________Rejected__________________________________________________________________________ Signature of Interviewing Officer_________________________________________________________________________________ 1/31/14 Page 1 of 4 APPLICANT TO COMPLETE (answer all questions ‐ please print) Position(s) Applied for__________________________________________________________________________________________ Name_________________________________________________________________Social Security No._______________________ Last First Middle Phone _________________________________________Email ________________________________________________________ List your addresses of residency for the past 5 years. Current _____________________________________________________________________________________________________ Address Street City _____________________________________________________________________________ How Long?______________ State Zip Code yr./ mo. Previous_____________________________________________________________________________________________________ Address Street City ______________________________________________________________________________How Long?______________ State Zip Code yr./ mo. Previous_____________________________________________________________________________________________________ Address Street City ______________________________________________________________________________How Long?______________ State Zip Code yr./ mo. Do you have the legal right to work in the United States? _________________________________________________________ (In accordance with the Federal Immigration and Reform Act of 1986) Have you worked for this company before? _____Where?___________________________________________________ Dates: From_______________ To_____________ Rate of Pay_______________ Position_________________________ Reason for leaving ___________________________________________________________________________________ Are you now employed? ___________ If not, how long since leaving last employment? ___________________________ Who referred you? ___________________________ Desired Salary: __________________Date available:____________ Have you ever been discharged or suspended while working for another company? _____If yes, explain. Education Circle highest grade completed: 1 2 3 4 5 6 7 8 High School: 1 2 3 4 College: 1 2 3 4 From: Name of Institution: From: Name of Institution: From: Name of Institution: From: To: To: To: To: Did you graduate? Did you graduate? Did you graduate? Did you graduate? YES NO Address: YES NO Address: YES NO Address: YES NO Degree Earned: Degree Earned: Degree Earned: Degree Earned: Signature: ________________________________________________________________________Date: ______________________ 1/31/14 Page 2 of 4 10 Year Employment History Any gaps in employment and/or unemployment must be explained. Please give an accurate, complete full time and part time employment record. Start with your present or most recent employer. If you need additional space, please use a separate sheet of paper. DO NOT indicate "see resume." _________________________________________ EMPLOYER _______________________________________________ Name:___________________________________________________________________Dates Employed____________ Address:_____________________________________________________________ From____________To __________ City:___________________________________________________ State:________________ Zip: __________________ Phone # (____) _____________Supervisor _______________________________ Position:_________________________ Responsibilities:_____________________________________________________________________________________ Reason for leaving___________________________________________________Rate of Pay_______________________ May we contact your present supervisor for a reference? U
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_________________________________________ EMPLOYER _______________________________________________ Name:___________________________________________________________________Dates Employed____________ Address:_____________________________________________________________ From____________To __________ City:___________________________________________________ State:________________ Zip: __________________ Phone # (____) _____________Supervisor _______________________________ Position:_________________________ Responsibilities:_____________________________________________________________________________________ Reason for leaving___________________________________________________Rate of Pay_______________________ May we contact your present supervisor for a reference? U
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_________________________________________ EMPLOYER _______________________________________________ Name:___________________________________________________________________Dates Employed____________ Address:_____________________________________________________________ From____________To __________ City:___________________________________________________ State:________________ Zip: __________________ Phone # (____) _____________Supervisor _______________________________ Position:_________________________ Responsibilities:_____________________________________________________________________________________ Reason for leaving___________________________________________________Rate of Pay_______________________ May we contact your present supervisor for a reference? U
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_________________________________________ EMPLOYER _______________________________________________ Name:___________________________________________________________________Dates Employed____________ Address:_____________________________________________________________ From____________To __________ City:___________________________________________________ State:________________ Zip: __________________ Phone # (____) _____________Supervisor _______________________________ Position:_________________________ Responsibilities:_____________________________________________________________________________________ Reason for leaving___________________________________________________Rate of Pay_______________________ May we contact your present supervisor for a reference? U
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_________________________________________ EMPLOYER _______________________________________________ Name:___________________________________________________________________Dates Employed____________ Address:_____________________________________________________________ From____________To __________ City:___________________________________________________ State:________________ Zip: __________________ Phone # (____) _____________Supervisor _______________________________ Position:_________________________ Responsibilities:_____________________________________________________________________________________ Reason for leaving___________________________________________________Rate of Pay_______________________ May we contact your present supervisor for a reference? U
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Signature: ________________________________________________________________________Date: ______________________ 1/31/14 Page 3 of 4 Criminal History Have you ever tested positive or refused to take a drug or alcohol test, pre‐employment or otherwise? If yes, give date. ____________________________________________________________________________________________________________ Have you ever been convicted of a crime; felony or misdemeanor? _____ If yes, explain fully on a separate sheet of paper. (Conviction of a crime does not necessarily exclude you from employment.) Consideration will be given to all circumstances. Do you have any charges pending? _____ If yes, give date and details.___________________________________________________ ____________________________________________________________________________________________________________ References Please list three professional references. Full Name: Relationship:
Company: Phone:
(
)
Phone:
(
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Phone:
(
)
Address: Full Name: Relationship:
Company: Address: Full Name: Relationship:
Company: Address: Other ‐ Experience and Qualifications Skills and Qualifications: Licenses, Skills, Training or Awards: Types of computers, other electronic or mechanical equipment that you are qualified to operate or repair: Additional skills including supervision skills, other languages, or information regarding the career/ occupation you wish to bring to the employer’s attention:
I certify that this application was completed by me, and that all entries on it are true and complete to the best of my knowledge. Signature: _______________________________________________________________________Date: _______________________ 1/31/14 Page 4 of 4 REQUEST FOR CHECK OF DRIVING RECORD
NOTE TO MOTOR CARRIER: SEE BACK SIDE FOR STATES THAT ACCEPT THIS FORM.
I hereby authorize your to release the following information to BEAM BROS. TRUCKING, INC. for purposes of
(Prospective Employer)
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
I also hereby certify that 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
103-322, Title XXX, Section 300002(a)).
(Signature of Requester)
(Date)
TO:
BEAM BROS. TRUCKING, INC.
P. O. BOX 183
MT. CRAWFORD, VIRGINIA 22841
DEAR SIR/MADAM:
The following named person has made application with our company 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 three years.
The following named person is employed with our company in the position of
.
In accordance with Section 391.25, Federal Department of Transportation Regulations, please furnish the undersigned with
the employee's driving record for the past year.
NAME OF APPLICANT/DRIVER______________________________________________________________________
ADDRESS ______________________________________________________________________________________
(Number & Street)
(City)
(State)
(Zip Code)
FORMER ADDRESS_______________________________________________________________________________
(Number & Street)
(City)
(State)
(Zip Code)
DATE OF BIRTH____________________ SSN_______________________ LICENSE NO._____________________
REQUESTED BY
(City)
(Name of Company)
(Typed Name)
(Address)
(Title)
(State)
(Signature)
9/19/14 APPLICANT/EMPLOYEE INVITATION TO SELF-IDENTIFY
PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM
Beam Bros. Trucking, Inc. is subject to certain governmental record keeping and reporting requirements for the
administration of civil rights laws and regulations. In order to comply with these laws, we invite applicants and
employees to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary.
Refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and
will be used only in accordance with the provisions of applicable laws, executive orders and regulations,
including those that require the information to be summarized and reported to the federal government for civil
rights enforcement. When reported, data will not identify any specific individual.
Name: _____________________________Position Held/Position Applied for: ___________________________
Gender:
Male
Female
Please check only one box.
Hispanic or Latino, Regardless of Race: A person of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin.
All Other Categories (Not Hispanic or Latino):
American Indian or Alaskan Native: A person having origins in any of the original peoples of
North and South America (including Central America), and who maintain tribal affiliation or community
attachment.
Black or African American: A person having origins in any of the black racial groups of Africa
White: A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand, and Vietnam.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
Two or More Races: All persons who identify with more than one of the five races listed above in
All Other Categories. If you choose this category and there is a race category with which you primarily
identify, please feel free to list it:____________________________________________.
Anti-Discrimination Notice. Beam Bros. Trucking, Inc. is an Equal Opportunity Employer. It is an
unlawful employment practice for an employer to fail or refuse to hire any individual or otherwise to
discriminate against any individual with respect to their terms or conditions of employment because of
the individual’s race, color, national origin, sex, age, religion, disability, veteran or marital status or any
other status protected by federal, state or local law. If you have any concerns or questions regarding
discrimination or harassment, please contact Human Resources.
_________________________________
Applicant/Employee Signature
____________________________________
Date
INVITATION TO SELF-IDENTIFY / PRE OFFER
VETERANS
Beam Bros. Trucking, Inc. is a Government contractor subject to the Vietnam Era Veterans'
Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212
(VEVRAA), which requires Government contractors to take affirmative action to employ and advance
in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or
campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are
defined as follows:

A "disabled veteran" is one of the following:

a veteran of the U.S. military, ground, naval or air service who is
entitled to compensation (or who but for the receipt of military retired
pay would be entitled to compensation) under laws administered by
the Secretary of Veterans Affairs; or

a person who was discharged or released from active duty because of a
service-connected disability.

A "recently separated veteran" means any veteran during the three-year period
beginning on the date of such veteran's discharge or release from active duty in the
U.S. military, ground, naval, or air service.

An "active duty wartime or campaign badge veteran" means a veteran who served on
active duty in the U.S. military, ground, naval or air service during a war, or in a
campaign or expedition for which a campaign badge has been authorized under the
laws administered by the Department of Defense.

An "Armed Forces service medal veteran" means a veteran who, while serving on
active duty in the U.S. military, ground, naval or air service, participated in a United
States military operation for which an Armed Forces service medal was awarded
pursuant to Executive Order 12985.
Protected veterans may have additional rights under USERRA - the Uniformed Services Employment
and Reemployment Rights Act. In particular, if you were absent from employment in order to perform
service in the uniformed service, you may be entitled to be reemployed by your employer in the position
you would have obtained with reasonable certainty if not for the absence due to service. For more
information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS),
toll-free, at 1-866-4-USA-DOL.
5/16/14
If you believe you are a member of any of the categories of protected veterans listed above, please
indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we
request this information in order to measure the effectiveness of the outreach and positive recruitment
efforts we undertake pursuant to VEVRAA.
[ ]
I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF
PROTECTED VETERAN LISTED ABOVE
[ ]
I AM NOT A PROTECTED VETERAN
Submission of this information is voluntary and refusal to provide it will not subject you to any adverse
treatment. The information provided will be used in a manner not inconsistent with the Vietnam Era
Veterans' Readjustment Assistance Act of 1974, as amended.
The information you submit will be kept confidential, except that (i) supervisors and managers may be
informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary
accommodations; (ii) first aid and safety personnel may be informed, when and to the extent
appropriate, if you have a condition that might require emergency treatment; and (iii) Government
officials engaged in enforcing laws administered by the Office of Federal Contract Compliance
Programs, or enforcing the Americans with Disabilities Act, may be informed.
This Organization abides by the requirements of 41 CFR Section 60-300.5(a). This regulation requires
affirmative action by covered contractors to employ and advance in employment qualified protected
veterans.
_____________________________________
Printed Name
_____________________________________
_________________
Signature
Date
5/16/14
2
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 1 of 2
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to
qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you
have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will
choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used
against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may
become disabled at any time, we are required to ask all of our employees to update their information every five
years. You may voluntarily self-identify as having a disability on this form without fear of any punishment
because you did not identify as having a disability earlier.
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that
substantially limits a major life activity, or if you have a history or record of such an impairment or medical
condition.
Disabilities include, but are not limited to:
Blindness
Deafness
Cancer
Diabetes
Epilepsy
Autism
Cerebral palsy
HIV/AIDS
Schizophrenia
Muscular
dystrophy
Bipolar disorder
Major depression
Multiple sclerosis (MS)
Missing limbs or
partially missing limbs
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental
retardation)
Please check one of the boxes below:
☐
YES, I HAVE A DISABILITY (or previously had a disability)
☐
NO, I DON’T HAVE A DISABILITY
☐
I DON’T WISH TO ANSWER
__________________________
Your Name
__________________
Today’s Date
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 2 of 2
Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities.
Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples
of reasonable accommodation include making a change to the application process or work procedures,
providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
i
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal
employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract
Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required
to respond to a collection of information unless such collection displays a valid OMB control number. This
survey should take about 5 minutes to complete.