Application for Employment
Equal Opportunity Employer

Position(s) Applied for:

Date of Application:

/

/

Name:

(Last)

(First)

(Middle)

Nickname or other names you have used while working:

Street Address:

Apt./Unit No.:

City:

State:

Zip Code:

Mailing Address:

Apt./Unit No.:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Cell Provider:

Email Address:

Emergency Contact:

(Name)

(Relationship)

(Contact Number)

Social Security #:

-

-

Date of Birth:

/

/

Have you ever been employed by Elite HR Logistics before?

Yes

No

If yes, please give dates and position:

Can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?

Yes

No

Are you telephone accessible?

Yes

No

Are you willing to take a drug screen according to our policy?

Yes

No

Will you release your background information inclusive of criminal records?

Yes

No

What areas are you willing to work?

(Applicant Signature)

(Print Name)

(Date)

*No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, date of the offense, the surrounding circumstances, and the relevance of the offense to the

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 1 OF 8

position(s) applied for may, however, be considered.
*The ability to be bonded is a condition of hire: A Photograph and a copy of your fingerprints may be required as part of or during your employment.

Elite HR Logistics is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis
or race, color, creed, religion, ancestry, age, gender, marital status, sexual orientation, national origin, disability or handicap, or veteran status. We comply with all Federal, State, and Local laws concerning discrimination in employment.

NOTICE REGARDING BACKGROUND INVESTIGATION

Important – Please read carefully before signing acknowledgement

Employer Elite HR Logistics may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted CDTA Your national compliance solution,9275 Sky Park Court, Suite 105,San Siego,Ca.888.908.2382. or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, Authorizing the industrial commission of Arizona to release worker compensation record, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Corporate Screening Services, Inc., another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile (“fax”) or photographic copy of this Authorization shall be as valid as the original.

NOTICE REGARDING BACKGROUND INVESTIGATION
PURSUANT TO CALIFORNIA LAW

Employer (Elite HR Logistics) intends to obtain information about you from an investigative consumer reporting agency and/or a consumer credit reporting

agency for employment purposes. Thus, you can expect to be the subject of “investigative consumer reports” and “consumer credit reports” obtained for employment purposes. Such reports may include information about your character, general reputation, personal characteristics and mode of living. With respect to any investigative consumer report from an investigative consumer reporting agency (“ICRA”), the Company may investigate the information contained in your employment application and other background information about you, including but not limited to obtaining a criminal record report, verifying references, work history, your social security number, your educational achievements, licensure, and certifications, your driving record, and other information about you, and interviewing people who are knowledgeable about you. The results of this report may be used as a factor in making employment decisions. The source of any investigative consumer report (as that term is defined under California law) will be Corporate Screening Services, Inc., 16530 Commerce Court, Cleveland, OH 44130, Phone: 800-229-8606, Fax: (440) 243-4204. The source of any credit report will be [add name of credit bureau].

The Company agrees to provide you with a copy of an investigative consumer report when required to do so under California law.

Under California Civil Code section 1786.22, you are entitled to find out from an ICRA what is in the ICRA’s file on you with proper identification, as

follows:

In person, by visual inspection of your file during normal business hours and on reasonable notice. You also may request a copy of the information in person. The ICRA may not charge you more than the actual copying costs for providing you with a copy of your file.

A summary of all information contained in the ICRA’s file on you that is required to be provided by the California Civil Code will be provided to you via telephone, if you have made a written request, with proper identification, for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.

By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the ICRAs.

“Proper Identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional information concerning your employment and personal or family history in order to verify your identity.

The ICRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection.

You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file in such person’s presence.

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 2 OF 8

CALIFORNIA APPLICANTS OR EMPLOYEES ONLY

By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law.

(Full Legal Name)

(Previous Names Used)

(Dates Used)

/

/

-

(Date of Birth)

(Social Security Number)

(Current License No.)

(State)

List all residential addresses for the last 7 years. Begin with your most current and continue on back of sheet if needed.

(Street Address)

(City)

(State & Zip)

(Street Address)

(City)

(State & Zip)

(Street Address)

(City)

(State & Zip)

(Street Address)

(City)

(State & Zip)

Have you ever been convicted of a crime other than a minor traffic violation?

Yes

No

(Offense)

(Date)

(City)

(State)

Do you have any criminal proceeding pending?

Yes

No

(Applicant Signature)

(Print Name)

(Date)

ACKNOWLEDGEMENT OF AVAILABLE MODIFIED DUTY

Elite HR Logistics desires to provide our injured employees with the most expedient and quality medical care for their

work related injuries.

Elite HR Logistics has developed a modified duty program that will allow our injured workers to return to work on a modified duty status by making accommodations for any work restrictions as outlined by a company authorized physician.

I understand that failure to report for modified duty will be considered an unexcused absence, and I will not be paid for any days missed.

(Applicant Signature)

(Date)

(Recruiter Signature)

(Date)

AVAILABILITY

How were you referred to our company?

Date you are available for work:

/

/

Salary rate:

Minimum: $

/Hr

Desired: $

/Hr

Type of employment accepted:

Full-Time

Part-Time

Temporary

Temp to Hire

Direct Hire

On-Call

Hours available to work:

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

BEGINNING TIME

ENDING TIME

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 3 OF 8

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WORK EXPERIENCE

List all current and previous employment for a minimum of three (3) years beginning with your most recent employer. Account for all periods of unemployment. Include military service and any volunteer service that is relevant to the

position for which you are applying. Do not mark “See Resume”

Are you currently employed?

Yes

No

If ‘Yes’, may we contact your current employer?

(Applicant Name)

Yes

No

FROM

TO

EMPLOYER

PHONE

1.

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

2.

FROM

TO

EMPLOYER

PHONE

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

3.

FROM

TO

EMPLOYER

PHONE

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

4.

FROM

TO

EMPLOYER

PHONE

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

5.

FROM

TO

EMPLOYER

PHONE

JOB TITLE

PART-TIME

FULL-TIME

ADDRESS

IMMEDIATE SUPERVISOR AND TITLE

WERE YOU SUBJECTED TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED?

YES

NO

SUMMARIZE NATURE OF WORK AND JOB RESPONSIBILITIES

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f) www.elitehrlogistics.com 

PAGE 4 OF 8

REASON FOR LEAVING

REASON FOR LEAVING

REASON FOR LEAVING

REASON FOR LEAVING

REASON FOR LEAVING

STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$				□	YES	□	NO	
	□	WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$	□			□	YES	□	NO	
		WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$	□			□	YES	□	NO	
		WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$	□			□	YES	□	NO	
		WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

□
□

□
□
STARTING SALARY	□	HOURLY	WAS THE JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE, SUBJECT TO					
$				□	YES	□	NO	
	□	WEEKLY	THE ALCOHOL AND CONTROLLED SUBSTANCE TESTING REQUIREMENTS?					
ENDING SALARY	□	HOURLY		
$	□	WEEKLY		

ADDITIONAL QUESTIONS

Bobtail/Box truck Driving Experience:

years

Types of Equipment Operated:

All Driver Licenses Held in the past 3 years:

				

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?

Yes

No

If no, describe the functions that cannot be performed:

Do you have any relatives employed with this company?

Yes

No

If yes, please list their names and positions:

Have you submitted an application with Elite HR Logistics before?

Yes

No

Have you ever been bonded?

Yes

No

If yes, where:

Have you ever had security clearance?

Yes

No

If yes, at what level:

Have you obtained any special skills as a result of service in the military?

Yes

No

If yes, please describe:

Have you ever been convicted of a felony?
(Such conviction will not necessarily disqualify you from the position)

Yes

No

Have you ever been convicted of a misdemeanor which resulted in?

Yes

No

imprisonment within the previous 2-years

(Such conviction will not necessarily disqualify you from the position)

Do you have any other special skills or qualifications which you feel would make you suited for work?
(Example: Certified forklift operator, machinist, welder, assembly or warehouse, etc.)

Yes

No

If yes, please describe:

Do you have a license or certificate for a particular skill?

Yes

No

If yes, issuing state:

Certified in:

License or Certification #:

Have you ever worked as a temporary employee?

Yes

No

Company assigned to:

Temp Agency:

Company assigned to:

Temp Agency:

Company assigned to:

Temp Agency:

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 5 OF 8

STATE

LICENSE #

CLASS

EXP DATE

STATE

LICENSE #

CLASS

EXP DATE

STATE

LICENSE #

CLASS

EXP DATE

EDUCATIONAL BACKGROUND

Give record of all High Schools, Colleges, Universities, Trade or Vocational Schools you have attended.

REFERENCES

List the three persons not related to you who have knowledge of your work performance within the last three years.

ACCIDENT RECORD PAST 3 YEARS

DATE OF ACCIDENT

LOCATION OF ACCIDENT

TYPE OF VEHICLE OPERATED

1..

INJURIES:

YES

NO

FMCSA/DOT DEFINED ACCIDENT:

YES

NO

DOT PREVENTABLE ACCIDENT:

YES

NO

	

2..

DATE OF ACCIDENT

LOCATION OF ACCIDENT

TYPE OF VEHICLE OPERATED

INJURIES:

YES

NO

FMCSA/DOT DEFINED ACCIDENT:

YES

NO

DOT PREVENTABLE ACCIDENT:

YES

NO

	

3..

DATE OF ACCIDENT

LOCATION OF ACCIDENT

TYPE OF VEHICLE OPERATED

INJURIES:

YES

NO

FMCSA/DOT DEFINED ACCIDENT:

YES

NO

DOT PREVENTABLE ACCIDENT:

YES

NO

	

License Ever Revoked or Suspended by a State of Federal Agency?

Yes

No

State or Federal Agency that suspended License

Date of Suspension:

Please provide statement of circumstances:

3838 Watt Ave. Suite D-404|I Sacramento, CA 95821

916-484-4300(p 916-484-7518(f) www.elitehrlogistics.com

PAGE 6 OF 8

CIRCUMSTANCESS 

EXPLANATION

CIRCUMSTANCESS 

EXPLANATION

CIRCUMSTANCESS 

EXPLANATION

NAME AND LOCATION	NUMBER OF YEARS
COMPLETED	MAJOR SUBJECT OR
COURSE	DEGREE OR
CERTIFICATE	
HIGH SCHOOL				
COLLEGE				
OTHER				
OTHER				

NAME AND ADDRESS	OCCUPATION	NUMBER OF YEARS
KNOWN	PHONE NUMBER	

				

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FACTS ABOUT SEXUAL HARASSMENT

(THE U.S. EQUAL EMPLOYMENT OPPORTUNITY COMMISSION)

Sexual harassment is a form of sex discrimination that violates Title VII of the Civil Rights Act of 1964. Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitutes sexual harassment when submission to or rejection of this conduct explicitly or implicitly affects an
Individual’s employment, unreasonably interferes with an individual's work performance or creates an intimidating,

hostile or offensive work environment.

Sexual harassment can occur in a variety of circumstances, including but not limited to the following:

•	The victim as well as the harasser may be a woman or a man. The victim does not have to be of the opposite sex.

•	The harasser can be the victim's supervisor, an agent of the employer, a supervisor in another area, a co-worker,

or a non-employee.
The victim does not have to be the person harassed but could be anyone affected by the offensive conduct.

Unlawful sexual harassment may occur without economic injury to or discharge of the victim.

•	The harasser's conduct must be unwelcome. It is helpful for the victim to directly inform the harasser that the conduct is unwelcome and must stop. The victim should

use any employer complaint mechanism or grievance system available.

When investigating allegations of sexual harassment, EEOC looks at the whole record: the circumstances, such as the nature of the sexual advances, and the context in which the alleged incidents occurred. A determination on the allegations

is made from the facts on a case-by-case basis.

Prevention is the best tool to eliminate sexual harassment in the workplace. Employers are encouraged to take steps necessary to prevent sexual harassment from occurring. They should clearly communicate to employees that sexual harassment will not be tolerated. They can do so by establishing an effective complaint or grievance process and taking immediate and appropriate action when an employee complains.

By signing this document, Elite HR Logistics has provided you with information regarding harassment in the work place.

(Applicant Signature)

(Print Name)

(Date)

PLEASE READ EACH CARFULLY, INITIAL EACH PARAGRAPH AND SIGN BELOW

I hereby certify that I have not knowingly withheld any information that may adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material facts on this application or on any document used to secure employment shall be grounds for rejection of this application of for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I hereby authorize the Company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the Company any and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigations or disclosure.

In compliance with Federal regulations, the Company requires each applicant upon hire to submit verification of identity and employment authorization to work in the United States. Original, authentic documentation is mandatory. If hired, I can submit original authentic documents that will verify my identity and demonstrate my employment authorization to work in the United States of America. I understand that the use of fraudulent documentation or documents that were lawfully issued to another person may result in a fine or imprisonment of up to five (5) years, or both. Use of altered cards or fraudulent cards is grounds for termination.

I acknowledge that any employment offered by the Company has no specified term and may be terminated by the employer or the employee at will, with or without cause. I further acknowledge that this At Will statement is not alterable except by a written agreement signed by the Company President and myself.

(Applicant Signature)

(Print Name)

(Date)

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) | 916-484-7518(f)
www.elitehrlogistics.com 

PAGE 7 OF 8

PLEASE READ CARFULLY AND SIGN BELOW

APPLICANT NAME

SOCIAL SECURITY NUMBER

r

e

APPLICANT SIGNATURE

DATE

PREVIOUS COMPANY NAME

STREET

CITY

STATE

ZIP

TO FORMER EMPLOYER: Please give the following information about this applicant. It will be held in strict confidence.

DESCRIPTION

EXCELLENT

GOOD

FAIR

POOR

1. Is employment record with your Company correct?

2. Why did applicant leave?

3. If Company policy allowed, would you rehire?

4. Did he have custody of money or valuables?

5. Qualified in what equipment?

6. How many total accidents?

How many FMCSA defined recordable accidents?

7. Driver’s license ever revoked or suspended?

COMMENTS:

Completed By:

(Signature)

(Printed Name)

(Title)

(Date)

3838 Watt Ave. Suite D-404 | Sacramento, CA 95821

916-484-4300(p) 916-484-7518(f) www.elitehrlogistics.com 

PAGE 8 OF 8

SUPERVISORS NAME

TELEPHONE #

/

/

FROM

TO

YR.

YR.

MO.

MO.

PERIOD OF EMPLOYMENT

POSITION HELD

-	  -

Quality of Work					
Cooperation with others					
Safety habits					
Driving Skills					
Attendance Record					

Date Sent/Initial	2nd Request/Date Initial	3rd Request/Date Initial	

 		

I hereby authorize Elite HR to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and authorize the references I have listed to disclose to Elite HR and all letter, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Elite HR, my former employers and other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such