Transportation Providers Application Form
PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE
Date: 
APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS
APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGSName: Last First Middle
Present Address: Number Street City State Zip
How Long at this address? Social Security Number:
Telephone: Email:
If under 18, please indicate age:
Position Applying For: Desired Salary:
Desired Salary:How many hours can you work? When available for work?
EDUCATION AND OTHER INFORMATION
Type of School Name of School Location Years Completed Degree / Diploma
High School
College
Business/Trade School
Professional School
Have you ever been convicted of a crime?
What is your means of transportation to work?
Do you have a driver’s license?
Driver’s License / I.D.#: State of Issue: Expiration:
Have you had any accidents in the past five years? How many?
Have you had any moving violations in the past five years? How many?
MILITARY
Have you ever been in the armed forces?
Are you now a member of the National Guard?
Specialty: Date Entered: Date Discharged:
WORK EXPERIENCE
Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, please give firm name. Use additional sheets if necessary.
Job One
Name of employer: Name of Supervisor: Employment Salary
Dates
Current Address: From: Start:
Phone Number: Your Job Title: To: Final:
Reason for Leaving (be specific):
List the job titles you held, duties performed, skills used or learned, advancements or promotions while you worked with this company:
May we contact this employer?
Job Two
Name of employer: Name of Supervisor: Employment Salary
Dates
Current Address: From: Start:
Phone Number: Your Job Title: To: Final:
Reason for Leaving (be specific):
List the job titles you held, duties performed, skills used or learned, advancements or promotions while you worked with this company:
May we contact this employer?
Job Three
Name of employer: Name of Supervisor: Employment Salary
Dates
Current Address: From: Start:
Phone Number: Your Job Title: To: Final:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked with this company:
May we contact this employer?
TECHNICAL SKILLS
Microsoft Word:
Microsoft Excel:
Microsoft Outlook:
Microsoft Publisher:
Microsoft Access:
Other:
REFERENCES
Please list two references other than relatives or previous employers
Name: Position: Company:
Address: Phone: Email:
Name: Position: Company:
Address: Phone: Email:
Name: Position: Company:
Address: Phone: Email:
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to add any additional information necessary to describe your full qualifications for the specific position for which you are applying.
PLEASE READ CAREFULLY
APPLICATION FORM WAIVER
In exchange for my consideration of my job application, Star Treatment Transportation LLC. (hereinafter called “the Company”), I agree that:
Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Star Treatment Transportation LLC., or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and the relationship cannot be altered except by a written instrument signed by the Executive Director of the Company. Both the undersigned and Star Treatment Transportation LLC. may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.
I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job related physical examinations.
I understand that, in connection with the routine of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.
I further understand that my employment with the Company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will or for any reason by either party.
Applicant Name Date
This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race. color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.
Thank you for completing this application form and for your interest in our business.
165 Commerce Dr. Suite B, Fayetteville, Ga 30214 | (770) 719-2500 | Mon - Fri 7:00 AM - 7:00 PM, Sat - 7 AM - Noon
(770) 719-2500
165 Commerce Dr., Suite B
Fayetteville, Ga 30214
