Virginia Employment Application Form – KVWV Traffic Control, Inc.

Before completing this form, make sure you have digital copies of your Driver’s License, your Driving Records, and CDL Exam (if you have one).

If you have ever refused a drug/alcohol test, or have tested positive on such an exam (outside of work or while previously employed), you will need a copy of your proof of Return to Duty Process to attach as well.

KVWV Employment Application (Virginia)

Employment application form for Virginia residents

Step 1 of 13

Your Personal Information

Your Name(Required)

First Middle Iniitial Last

Date of Birth(Required)

MM slash DD slash YYYY

Social Security Number(Required)

Your Email Address(Required)

Enter Email Confirm Email

Current Address(Required)

Please list your current address of residency below.

Street Address Address Line 2 City State ZIP Code

Have you lived in a previous address in the last THREE years?

Yes

Previous Address

Please list your previous address of residency for the last THREE years below, if applicable.

Street Address Address Line 2 City State ZIP Code

Have you lived at an additional address during the last THREE years?

Yes

Previous Address(s)

Please list your previous address(s) of residency for the last THREE years below, if applicable.

Street Address Address Line 2 City State ZIP Code

Home Phone Number / Primary Contact Number(Required)

Cell Phone Number / Alternate Contact Number(Required)

Best Time To Call You

When is the best time for us to reach you via telephone?

Which Position Are You Applying For?

Position You're Applying For(Required)

Mechanic / Shop

CDL Driver / Operator / Laborer

Expected Rate of Pay (hourly):(Required)

Were you referred to this position? If so, by who?

Date Available for Work(Required)

When are you available to begin working?

MM slash DD slash YYYY

Overtime, Weekends, & Travel are required. Will this be a problem?(Required)

Yes

Employment History

Your Previous Employers

Please list your previous employers, the dates you worked and the position you held

Employer

Dates

Position

Phone

Employment Validation Information

Are you a Citizen of the United States?(Required)

Yes

If NO, are you authorized to work in the United States?

Yes

Can you provide Proof of Age?(Required)

Yes

Have you ever worked for KVWV Before?(Required)

Yes

If YES, when, and what was your reason for leaving?

Have you ever been convincted of a felony?(Required)

Yes

If YES, explain:

Are you Currently Employed?(Required)

Yes

If NO, how long since your last employment?

JOB REQUIREMENTS:(Required)

A flexible schedule is a must! Work schedule includes days, nights, weekend work and travel. Work hours vary depending on work load & weather. Physical requirements include but are not limited to: Exerting up to 50 pounds of force to lift, carry, push and pull or otherwise move objects including the human body, climbing short ladders, standing, walking stooping, kneeling, crouching and sitting. Employee may be subject to both outside & inside environmental conditions and harsh weather conditions while on job sites. You must have reliable transportation, valid driver’s license, good driving record, pass pre-employment, post-accident & random drug testing and must pass a Traffic/Flagger course. Is there ANY reason you might be unable to perform the functions of the job listed above for which you have applied?

Yes

If YES, please explain here:

Education

Please indicate your highest level of education completed.

The Highest level of eductation I have completed is:

Elementary School

High School

College

I have completed X years in elementary school:

I have completed X years of High School or College:

Do you have a G.E.D.?

Yes

What was the Name, City, and State of the last school you attended?

Driver's License and Driving History Information

Do you have a valid Driver's LIcense?(Required)

Yes

License Number:

State License was Issued:

Expiration Date

MM slash DD slash YYYY

Do you have a valid CDL (Commercial Driver's License)?(Required)

Yes

State License was Issued:

Date of Issue:

MM slash DD slash YYYY

Medical Exam Expire Date:

MM slash DD slash YYYY

Do you have any Limitations?(Required)

Yes

If YES, list them here:

Driver Experience

If you have no applicable experience, type NONE below for Type of Equipment.

List

Example equipment: Straight Truck, Tractor & Semi Trailer, Tractor-Two Trailers, Motor Coach, School Bus, Van, Tandem, Flat

Type of Equipment

FROM (Date)

TO (Date)

Approx. # of Miles (Total)

REQUIRED QUESTIONS

1. Have you ever been denied a license, permit or privilege to operate a motor vehicle?(Required)

Yes

2. Has any license, permit or privilege ever been suspended or revoked?(Required)

Yes

3. Have you ever been convicted of a criminal act involving the use of a CMV or while driving a CMV?(Required)

Yes

4. Have you ever been convicted of any law violation?(Required)

(Include any plea of “Guilty” or “No Contest” except for minor traffic violation)

Yes

Explanation:

If you answered YES to any of the above questions, please give a statement of explanation below.

Incident History / Additional Information

LIST ANY ACCIDENTS FOR PAST THREE (3) YEARS:

Date

Nature of Accident (Head-on, Rear-End, etc)

# of Injuries

# of Fatalities

LIST ANY TRAFFIC CONVICTIONS & FORFEITURES FOR PAST THREE (3) YEARS:

Date

Location

Charge

Penalty

LIST STATES OPERATED IN FOR PAST FIVE YEARS:

LIST SPECIAL DRIVING COURSES OR TRAINING COMPLETED:

LIST SAFE DRIVING AWARDS YOU HOLD AND FROM WHOM:

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding three (3) years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle in intrastate commerce shall also provide an additional seven (7) years’ information on those employers for whom the applicant operated such vehicle.

Checking here certifies that the driver had no previous employment experience working for a DOT regulated employer during the preceding three years.

I have NO EXPERIENCE with a DOT-Regulated Employer (in last THREE years)

Most Recent Employer

Phone #

Address

Street Address Address Line 2 City State ZIP Code

Supervisor Name

Supervisor Phone #

Position Held

Starting Salary/Wage

Ending Salary/Wage

Responsibilities

Date Started (Month/Year)

Date Ended (Month/Year)

Reason for Leaving

May we contact your previous supervisor for a reference?

YES

Were you subject to the FMCSRs while employed?

YES

Previous Employer

Phone #

Address

Street Address Address Line 2 City State ZIP Code

Supervisor Name

Supervisor Phone #

Position

Starting Salary/Wage

Ending Salary/Wage

Responsibilities

Date Started (Month/Year)

Date Ended (Month/Year)

Reason for Leaving

May we contact your previous supervisor for a reference?

YES

Were you subject to the FMCSRs while employed?

YES

Previous Employer

Phone #

Address

Street Address Address Line 2 City State ZIP Code

Supervisor Name

Supervisor Phone #

Position Held

Starting Salary/Wage

Ending Salary/Wage

Responsibilities

Date started (Month/Year)

Date Ended (Month/Year)

Reason for Leaving

May we contact your previous supervisor for a reference?

YES

Were you subject to the FMCSRs while employed?

YES

Military Service (If Applicable)

Branch

From

Rank at Discharge

Type of Discharge

If other than Honorable, explain:

DECLARATION OF EMPLOYMENT STATUS (GAPS IN HISTORY)

IF YOU WERE DRIVING A CMV, YOU MUST PROVIDE COMPLETE EMPLOYMENT HISTORY FOR THE PAST 10 YEARS. ANY GAPS IN EMPLOYMENT LONGER THAN 1 MONTH ARE EXPLAINED AS FOLLOWS:

Activity During Break

From (Month / Year)

To (Month / Year)

In Addition, I was not employed by any company or individual .

YES

Activity During Break

From (Month / Year)

To (Month / Year)

In Addition, I was not employed by any company or individual .

YES

Activity During Break

From (Month / Year)

To (Month / Year)

In Addition, I was not employed by any company or individual .

YES

List any additional gaps, fill in details here:

EXPERIENCE, QUALIFICATIONS OR SKILLS THAT MAY HELP IN YOUR WORK FOR K.V.W.V.

Certifications

OSHA, CPR, 1st Aid, Forklift, etc., Courses/Training, Trucking, Transportation, Professional Licenses, Equipment or Technical Training, Computer Skills, Foreign Languages, Etc.

PLEASE LIST HERE IF YOU HAVE EXPERIENCE IN:

ROAD STRIPING, INSTALLING REFLECTIVE PAVEMENT MARKERS, PARKING LOT STRIPING, SEALCOATING, FLAGGER, TRAFFIC CONTROL, MECHANIC ABILITIES OR ANYTHING PERTAINING TO THIS PARTICULAR LINE OF WORK, ETC.

References

PLEASE LIST THREE REFERENCES --- PLEASE PROVIDE GOOD PHONE NUMBERS

Full Name

Relationship

Company

Phone #

Address

Full Name

Relationship

Company

Phone #

Address

Full Name

Relationship

Company Name

Phone #

Address

IS THERE ANYTHING ELSE YOU WANT US TO KNOW PRIOR TO CHECKING REFERENCES?

PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION

Information:(Required)

I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date.

I authorize K.V.W.V. Traffic Control, Inc. to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a physical exam, criminal and credit background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that employees of K.V.W.V. Traffic Control, Inc. serve at-will, and the employment relationship may be terminated at any time by either party, for any or no reason, other than a reason prohibited by law. I also understand that if I violate the company drug & alcohol policy, I will be subject to disciplinary action including termination and may not be entitled to Workers Comp or Unemployment Benefits.

If employed, I will be required to furnish proof of eligibility to work in the United States, to file a State security questionnaire and State loyalty oath, and to comply with company and departmental regulations. I understand that if employed on a temporary basis, I would be paid for hours worked only, and would be ineligible for benefits including paid time off. If employed on a regular, benefits-eligible basis, I understand that any benefits I receive may be subject to change or iscontinuation at any time without prior notice. I understand that the first Six Months of regular employment represents a provisional
period, during which I would not be eligible to apply for transfer or promotion and during which I may be terminated without right of appeal.

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
In accordance with the provisions of Section 604(b)(2)(A) 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 I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. Your employer may obtain this information from Equifax, Trans Union, Experian or other vendors of
information services.

I Understand and Accept the Above Information

ALCOHOL AND CONTROLLED SUBSTANCE CONSENT AND RELEASE

Have you ever refused to be tested for drugs or alcohol?(Required)

YES

Have you ever tested positive for drugs or alcohol?(Required)

YES

Have you ever tested positive for any pre-employment drug or alcohol test for a job which you applied for but did not obtain?(Required)

YES

If you answered yes to any of the above questions, please provide a statement of explanation here:

Provide proof of Return to Duty Process

If you answered yes to any of the above questions, please attach proof of Return to Duty Process. Accepted file types include: pdf, doc, docx, jpg, jpeg, png, bmp

Accepted file types: pdf, doc, docx, jpg, jpeg, png, bmp, Max. file size: 25 MB.

Alcohol & Controlled Substances Testing(Required)

I understand that, as required by the Federal Motor Carrier Safety Regulations or company policy, all
drivers must submit to alcohol and controlled substance testing as a condition of employment. I also understand that any offer of employment will be contingent upon the results of an alcohol and controlled substance test.

Therefore, I agree to submit to the following alcohol and controlled substance tests in accordance and as defined by the Federal Motor Carrier Safety Regulation and this company’s policies:

•Pre-Employment, to determine employment eligibility
•Random
•Reasonable Suspicion
•Post Accident
•Follow Up (see company policy)
•Return-to-Duty (see company policy)

I certify that I have read, understand, and agree to abide by the condition of this consent and release form.

Applicant Name(Required)

Date(Required)

MM slash DD slash YYYY

Social Security Number(Required)

Do you certify that the above information is correct, and that you authorize use of your Social Security Number in this application process?(Required)

YES

DRIVING RECORDS

I understand that as a normal part of the hiring process the driving records of all prospective employees are reviewed. In addition, I understand that my driving record is subject to future, periodic reviews. By completing and signing this form, I give permission to K.V.W.V. Traffic Control, Inc. and its insurance agent to obtain and review a copy of my driver’s license (MVR) record both now and in the future.

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

MM slash DD slash YYYY

Driver's License Number(Required)

State Issued(Required)

Permission to Obtain Driving Record(Required)

I hereby grant permission to K.V.W.V Traffic Control, inc. and its insurance agent to obtain and review a copy of my driver's license record (MVR) both now and in the future.

“AT-WILL POLICY STATEMENT”

I understand that employment with K.V.W.V. Traffic Control, Inc. is voluntarily entered into, and you are free to resign from your position with the company at will, at any time, with or without cause. Similarly, K.V.W.V. Traffic Company, Inc. may terminate the employment relationship at will at any time, with or without cause, so long as there is no violation of applicable federal or state laws. Employment is on a conditional basis until I can demonstrate that I have the skills necessary to perform the job for which I am hired. Initial Employment is offered on a ninety day (90 day) trial period unless the company deems it necessary to terminate the relationship sooner. At the conclusion of this 90 day trial period, you will be evaluated for permanent employment. In the event of employment, I understand that false or misleading information given in my application may result in discharge. I understand also, that I am required to abide by all rules and regulations of the Company.

Agreement with At-Will Policy Statement(Required)

I agree to the At-Will Policy Statement as outlined above.

Required File Upload

Here you will be required to upload copies of your Driver's License and CDL Exam (if applicable).

Upload Your Driver's License(Required)

Upload your Driver's License in .pdf, .doc or .docx format, or as an image using .jpg/.jpeg, .png, or .bmp format.

Accepted file types: pdf, doc, docx, jpg, jpeg, png, bmp, Max. file size: 25 MB.

Upload Your Driving Records(Required)

Upload your Driving Records in .pdf, .doc or .docx format

Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Upload Your CDL Exam

Upload your CDL Exam in .pdf, .doc or .docx format

Accepted file types: pdf, doc, docx, jpg, jpeg, png, bmp, Max. file size: 25 MB.