Fields in red are required

Qualified applicants receive equal consideration. No question is asked for the purpose of excluding any applicant due to race creed, color, national origin, religion, age sex, veteran status, disability, or any other characteristics, as prohibited by law or regulation.

"AN EQUAL OPPORTUNITY EMPLOYER"

Thank you for your interest in Jack B. Kelley, Inc., where "Safety is First". Please take just a moment and complete the following information. If you have questions or would like to expedite your application, call our friendly JBK recruiters at 1-800-225-5525 ext. 260.

Please complete all fields. Incomplete applications may be rejected.

PERSONAL INFORMATION

How did you hear about Jack B. Kelley?

Position Applied for:           Company Driver Owner Operator Lease Driver

Name:   Home Phone:   Cell Phone/Other Number:   Email:

Present Address:   City:   State:   Zip:

Social Security No:        Date of Birth:    (per 49 CFR 391.21 b2)

Previous address last three (3) years
Address:   City:   State:   Zip:
Address:   City:   State:   Zip:
Address:   City:   State:   Zip:

EMPLOYMENT INFORMATION

Are you currently employed? Yes No
Do you authorize us to contact your present employer? Yes No
This company will hire only U. S. citizens and aliens lawfully authorized to work in the U. S. Do you qualify? Yes No
If employed can you provide proof of U. S. citizenship and identity, or if an alien, proof of authorization to work in the United States and proof of identity? Yes No

LIST EMPLOYMENT FOR THE PAST TEN (10) YEARS INCLUDE UNEMPLOYED PERIODS (Most Recent First)
Employer:   From:   To:

Address:   City:   State:   Zip:

Phone:   Position Held:

Reason for leaving:

Employer:   From:   To:

Address:   City:   State:   Zip:

Phone:   Position Held:

Reason for leaving:

Employer:   From:   To:

Address:   City:   State:   Zip:

Phone:   Position Held:

Reason for leaving:

Employer:   From:   To:

Address:   City:   State:   Zip:

Phone:   Position Held:

Reason for leaving:

Employer:   From:   To:

Address:   City:   State:   Zip:

Phone:   Position Held:

Reason for leaving:

Employer:   From:   To:

Address:   City:   State:   Zip:

Phone:   Position Held:

Reason for leaving:

Employer:   From:   To:

Address:   City:   State:   Zip:

Phone:   Position Held:

Reason for leaving:

Employer:   From:   To:

Address:   City:   State:   Zip:

Phone:   Position Held:

Reason for leaving:

Employer:   From:   To:

Address:   City:   State:   Zip:

Phone:   Position Held:

Reason for leaving:

Employer:   From:   To:

Address:   City:   State:   Zip:

Phone:   Position Held:

Reason for leaving:

CDL Drivers are required to be available for dispatch 24 hours per day, 7 days per week.
If applying for a driving job, are you willing to comply with this requirement? 		Yes No

License History and Experience

Current
License Number:   State:   Type:   Endorsements:
  Issue Date:   Expiration Date:
Past1
License Number:   State:   Type:   End:
  Issue Date:   Expiration Date:
Past2
License Number:   State:   Type:   End:
  Issue Date:   Expiration Date:

Do you currently have a Class A CDL? Yes No
Do you have Hazardous Materials Endorsement? Yes No
Do you have tanker endorsement? Yes No
Do you possess more than one valid license from any state other than you current state of licensure? Yes No
If yes please explain:

Please check all boxes that apply:

Driving Experience
OTR   Regional   Local   Mountain   Snow/Ice

Number of states Driven

Equipment Operated

Tractor Trailer   Cargo Tank   Flatbed   Double/Triples   Straight Truck   Other

Accident record for the past five (5) years.

Have you had any accidents in the past 5 years? Yes No

If yes please complete the section below.

Dates:   Nature of Accident:   Fatalities:   Injuries:   $ Property Damage:
Dates:   Nature of Accident:   Fatalities:   Injuries:   $ Property Damage:
Dates:   Nature of Accident:   Fatalities:   Injuries:   $ Property Damage:

Traffic Convictions and forfeitures for the past three (3) years (other than parking violations)

Have you had any traffic convictions or forfeitures for the past 3 years? Yes No

If yes please complete the section below.

Dates:   Location:   Charge:   Penalty:
Dates:   Location:   Charge:   Penalty:
Dates:   Location:   Charge:   Penalty:

Have you ever been convicted of a felony? Yes No
Have you ever been convicted of a misdemeanor? Yes No
Have you ever been denied a license or permit to operate a vehicle? Yes No
Have you ever had any license or permit suspended or revoked? Yes No
Have you ever been disqualified to drive by Federal Regulations? Yes No
Have you ever been convicted of an alcohol or drug related motor vehicle offense or possession of illegal drugs or substances? Yes No
Have you ever failed an alcohol test? Yes No
Have you ever failed a controlled substance test? Yes No
Have you ever refused an alcohol or controlled substance test? Yes No
Have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules in the last two years? Yes No

If you answered Yes to any of the above questions, it will not disqualify you from employment. However, providing false information will result in your disqualification or termination. Please give details:

All information provided by me is true and correct to the best of my knowledge. I understand that omissions or misrepresentations may be cause for subsequent dismissal. I hereby authorize any former employer, person, firm, or corporation whether listed on this application or not including Jack B. Kelley, Inc to answer any and all questions and agree to hold all persons harmless for giving any and all truthful information within their knowledge or records. I understand that this is a preliminary application and not a contract to employ me. Furthermore, in the event that I am hired, my continued service to the company shall be completely voluntary and may be terminated at will at any time upon notice by either the company or myself. I agree to take and pass a physical examination by a physician at any time after employment as a condition of continued service. In the event the company advances me money or other things of value, or I otherwise become indebted financially to the company, I agree to repay the company and also agree that any wages or monies due me upon termination may be offset by payroll deduction against any such monies due the company.

Yes I agree to these terms
No I do not agree to these terms

Print Name: Last Name: First Name:

DISCLOSURE AND RELEASE

In connection with my application for employment or independent contractor information with your company, I understand that consumer reports which may contain public record information may be requested from USIS Commercial Services (“USIS”) DAC. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers’ compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from USIS/DAC concerning previous driving record requests made by other agencies, and state provided driving records.

I AUTHORIZE, WITHOUT RESERVATION; ANY PARTY OR AGENCY CONTACED BY USIS/DAC TO FURNISH THE ABOVE - MENTIONED INFORMATION.

I have the right to make a request form USIS/DAC, upon proper identification, as to the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which USIS/DAC has previously furnished within the two year period preceding my request by calling USIS Consumer Support at 1-800-381-0645. I hereby consent to your obtaining the above information from USIS/DAC Services, and I agree that such information which USIS/DAC has or obtains, and my employment history with you if I am hired, will be supplied by USIS/DAC to other companies which subscribe to USIS/DAC Services.

Notice of Rights under FRCA

I hereby authorize procurement of consumer reports(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.
Yes I agree to these terms
No I do not agree to these terms

Print Name: Last Name: First Name:

JACK B. KELLEY, INC.
AFFIRMATIVE ACTION QUESTIONNAIRE
Federal contractors are required to implement affirmative action procedures in employment. Federal contractors also are required to report annually on the inclusion of veterans from the three groups listed below. Prospective employees are requested to provide the information below so that the employing organization can comply with federal mandates. Provision of the information requested below is voluntary and will be kept confidential by the employing organization. Disclosure or refusal to provide the information will not subject the applicant to any adverse treatment and the information will be used only to support programs in accordance with the regulations.

Print Name: Last Name: First Name: Date:

Race (check one)
White (Not Hispanic or Latino) – All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Black or African American (Not Hispanic origin or Latino) – All persons having origins in any of the black racial groups of Africa.
Hispanic or Latino – All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – All persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) – All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, & Vietnam.
American Indian or Alaskan Native (Not Hispanic or Latino) – All persons having origins in any of the original peoples of North America and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above races.
I prefer not to answer.

Sex
Male
Female

Handicapped; an individual who has a physical or mental impairment which substantially limits one or more of such person’s major life activities, has a record of such impairment, or is regarded as having such an impairment.
Yes
No

CHARACTERISTICS OF TARGETED VETERAN GROUPS

Special Disabled Veteran

A) a veteran who is entitled to compensation (or who but for the receipt of military pay would be entitled to compensation) under laws administered by the Department of Veterans Affairs for a disability (a) rated at 30 % or more, or (b) rated at 10 or 20% in the case of a veteran who has been determined under Section 1506 to Title 38 U.S.C. to have a serious employment handicap:

and/or

B) a veteran who was discharged or released from active duty because of a service-connected disability.

Veteran of the Vietnam-Era

A) a veteran who served on active duty for a period of more than 180 days, and was discharged or released there from with other than a dishonorable discharge, if any part of such active duty occurred: (I) in the Republic of Vietnam between February 28, 1961 and May 7, 1975; or (II) between August 5, 1964 and May 7, 1975 in all other cases;

and/or

B) a veteran who was discharged or released from active duty for a service connected disability if any part of such active dury was performed: (I) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or(II) between August 5, 1964 and May 7, 1975

Other Veterans

A) a veteran with active duty service at any point between December 7, 1941 and April 28, 1952

and/or

B) a veteran who served on active duty in a campaign or expedition for which a campaign badge has been authorized. The campaign badges, service medals, and expeditionary medals that qualify under this criterion will be listed on the veteran's "Armed Forces of the U.S. Report of Transfer or Discharge", commonly known as the "DD-214 Form", if the veteran meets this criterion.