You are applying for the following job openings:

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First Name	Last Name	Email (optional)
Street Address
City	State/Province AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR Other PA PR RI SC SD TN TX UT VA VT WA WI WV WY Other	If Other : List State/Province (optional)
Zip Code/Postal Code	Country Canada USA Other
Primary Phone Home Cell	Other Phone (optional) Home Cell	Best Time to Call
Equal Opportunity Employer Do you wish to complete the Gender and Race/Ethnicity Voluntary Self-Identification information?		Yes No
Gender Identification Male Female	Race/Ethnicity Identification American Indian or Alaska Native (Not Hispanic or Latino) Asian (Not Hispanic or Latino) Black or African American (Not Hispanic or Latino) Hispanic or Latino Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) Two or More Races (Not Hispanic or Latino) White (Not Hispanic or Latino) Other
Where did you learn of job openings at New Penn?		craigslist CareerBuilder.com CareersInGear.com Employee Referral Employment Guide Monster.com New Penn Web Site Newspaper Ad Teamsters Web Site Unknown Walk-In Word of Mouth Yard Sign Other
	Employee Who Referred You: (optional)
Highest Grade Completed Elementary - grade 1 Elementary - grade 2 Elementary - grade 3 Elementary - grade 4 Elementary - grade 5 Elementary - grade 6 Elementary - grade 7 Elementary - grade 8 High School - grade 9 High School - grade 10 High School - grade 11 High School - grade 12 College - Year 1 College - Year 2 College - Year 3 College - Year 4 Other	Last School Attended
Are you at least 21 years old? (optional)		Yes No
Are you able to perform all the functions of the job(s) for which you are applying, with or without reasonable accomodation?		Yes No
If Security Threat Assessment certified, provide STA# (optional)

Have you ever been convicted of a Felony?	Yes No
Have you ever been convicted of a Misdemeanor?	Yes No
Are there charges currently pending against you for a crime other than a minor traffic infraction?	Yes No
Please explain (optional)

Driver Qualifications Current Qualifications Class A CDL Class B CDL Hazmat Endorsement None Last DOT Physical (mm/dd/yyyy) Truck Driving School Graduated (optional) Do you have 6 mos. or more LTL experience? Yes No YRCW Employment Are you currently a Seniority employee at a YRCW Company? Yes No Are you currently on layoff from a YRCW Company? Yes No Please check applicable company. YRC Holland Have you regularly performed CDL required driving for 2 or more years with a YRCW Company? Yes No Last date of employment with YRCW Company Service Center (Terminal) Union Local # 25 107 110 118 229 249 251 294 317 355 375 404 429 597 641 677 707 764 776 Other Drivers Licenses CDL Class/ State License# Endorsements Expiration Date AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR Other PA PR RI SC SD TN TX UT VA VT WA WI WV WY Other AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR Other PA PR RI SC SD TN TX UT VA VT WA WI WV WY Other AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR Other PA PR RI SC SD TN TX UT VA VT WA WI WV WY Other Enter any additional licenses in the comments section at the bottom of this form. A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No B. Has any license, permit, or privilege ever been revoked? Yes No C. Have you ever been disqualified subject to Section 391 of the Federal Motor Carrier Safety Regulations? Yes No If the answer to either A, B, OR C is "yes", please give details. Accident History Have you had any accidents in the past 3 years? Yes No If yes, please complete the information below. Date Fatalities? Injuries? Vehicles Towed? Nature of Accident (Head-On, Rear-End, etc) Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Traffic Convictions or Forfeitures Have you had any Traffic Convictions or Forfeitures in the past 3 years, other than parking violations? Yes No If yes, please complete the information below. Location Date Charge Penalty Dock Qualifications (optional) Please list your platform experience, years of each, and type of equipment you can operate (lift truck, pallet jack, etc.).

Employment History

Enter Information to Add for Previous Employer required fields problem Name Job Title Street Address City State AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR Other PA PR RI SC SD TN TX UT VA VT WA WI WV WY Other Zip Country Canada USA Other Phone Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy) If current employer, use today's date. Please enter an explanation for the gap, or overlap, of over 30 days between this and the employer you just previously entered: Reason for Leaving Brief Description of Duties Was your job designated as a safety sensitive function (such as driving) in any DOT regulated mode subject to drug and alcohol testing? Yes No Were you subject to the DOT Motor Carrier Safety Regulations while working for this employer? Yes No Equipment Operated Straight Truck Tractor & Semi-Trailer Tractor-Two Trailers Forklift Pallet Jack # of States Driven:

Have you worked for New Penn before? Yes No

Do you have 10 or more years of work experience/employment history? If you answer yes, please enter enough work history below to add up to 10 years or more. Yes No

Please enter your previous employers in reverse order, starting with the most recent/current employer.

Days Entered So Far: days - (about years) (Any overlapping dates have been removed from this total.) Dates: You entered:

Attachments & Comments (optional)
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