Form Page: DEANS_APPLICATION

Deans Inc.
409 Commerce Road
Artesia, NM 88210

Application for Employment

(575)748-3400 (voice)
(575) 748-3742 (fax)

Social Security #

Name

(First, Middle, Last)

Address

(Street, City, State, Zip, How Long at Address)

Addresses
For Past
Three Years

(Street, City, State, Zip, How Long at Address)

Best Time to Contact

Home Phone

Secondary Phone Number

Date Available to Work

Wages Expected

Position Applied For

Do you have any illness or disability that precludes or limits your ability to perform the job that you are applying for?

If you chose Yes, please explain

_____________________________________________________________________________________________________________

(The questions pertaining to Sex, Date of Birth, and Marital Status are voluntary)

Sex

Marital Status

Date of Birth

_____________________________________________________________________________________________________________

Experience and Qualifications - Driver

Drivers License

(State, License #, Type, Expiration Date)

Additional Licenses

(State, License #, Type, Expiration Date)

_____________________________________________________________________________________________________________

Accident Record for Past 3 Years or More

Nature of Accident/Violation 1

Date of Accidents & Violations 1

Nature of Accident/Violation 2

Date of Accidents & Violations 2

Date of Accidents & Violations 3

Nature of Accident/Violation 3

A) Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

B) Has any license, permit, or privilege ever been suspended or revoked?

C) Have you ever been convicted of a felony?

If the answer to A,B, or C above is Yes, Please explain in the box below

_____________________________________________________________________________________________________________

Employment Record

Note: DOT requires that employment for at least 3 years and/or commercial driving experience for the last 10 years be shown
(If more space is required then enter the information in the box at the end of this section)

Name

Current/Last Employer:

Address

Position Held

From

Salary

Reason for Leaving

Name

Second Employer:

Address

Position Held

From

Salary

Reason for Leaving

Name

Third Employer:

Address

Position Held

From

Salary

Reason for Leaving

Name

Fourth Employer:

Address

Position Held

From

Salary

Reason for Leaving

References

(Name, Address, Phone, Association, Years Acquainted)

Do you have any special skills?

_____________________________________________________________________________________________________________

To Be Read and Signed By Applicant

I hereby certify that this application was completed by me, and that all entries on it and information contained within it are true and complete to the best of my knowledge. I authorize Deans, Inc. or its agents to investigate or verify the information contained within this application. I also authorize Deans, Inc. or its agents to request information concerning my Motor Vehicle Driver Records to make a determination concerning my employment. I understand that I will be given a copy of these records if an employment decision is made as a result of these records. By typing my name and entering todays date I agree to these terms.

Date:

Name: