Gasco: Application for Hazmat Transportation Employment

Gasco Propane - Driver Application

Application for Hazmat Transportation Employment

Mail In - PDF Application Also Available - Click Here

Personal Information
First Name	Last Name	Social Security No. Ex. 123-45-6789
Phone Number Ex. 715-546-2244		Email Address Ex. [email protected]
Date of Birth

Current & Previous Residency (Past 3 Years)
Current Residence
Address	City	State	Zip Code Ex. 54562	How Long
Previous Residence 1
Address	City	State	Zip Code Ex. 54562	How Long
Previous Residence 2
Address	City	State	Zip Code Ex. 54562	How Long

License InformationSection 383.21 FMCSR states "No person who operates a commercial motor vehicle at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license. The information for which is listed below
State	License No.	Type	Exp. Date

Driving Experience
Type Of Equipment (Van, Tank, Flat, Etc.) Straight Truck Other		Dates From To	Approx. Total No. Of Miles

Accident Record For The Past 5 Years or more
Dates	Nature of Accident (Head-On, Rear-End, Upset, Etc.)	Number Fatalities	Number Injuries	Chemical Spills Yes No Yes No Yes No

Traffic Convictions and Forfeitures for Past 5 Years (Other Than Parking Violation)
Date Convicted	Violation	State of Violation	Penalty

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

Yes No

If yes, explain:

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

Yes No

If yes, explain:

Employment Record

Applicants that desire to drive in intrastate / interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).

Must List Complete Mailing Address: Street Number and Name, City, State, and Zip Code.

Last Employer
Name	Address	City	State	Zip Code Ex. 54562
Phone Number Ex. 715-546-2244	Position Held	Salary Use Annual / Ex. 50000
Supervisor	Reason for Leaving
From	To

Second Last Employer
Name	Address	City	State	Zip Code Ex. 54562
Phone Number Ex. 715-546-2244	Position Held	Salary Use Annual / Ex. 50000
Supervisor	Reason for Leaving
From	To

Third Last Employer
Name	Address	City	State	Zip Code Ex. 54562
Phone Number Ex. 715-546-2244	Position Held	Salary Use Annual / Ex. 50000
Supervisor	Reason for Leaving
From	To

Fourth Last Employer
Name	Address	City	State	Zip Code Ex. 54562
Phone Number Ex. 715-546-2244	Position Held	Salary Use Annual / Ex. 50000
Supervisor	Reason for Leaving
From	To

Fifth Last Employer
Name	Address	City	State	Zip Code Ex. 54562
Phone Number Ex. 715-546-2244	Position Held	Salary Use Annual / Ex. 50000
Supervisor	Reason for Leaving
From	To

Any Gaps In Employment And / Or Unemployment Must Be Explained. Include Dates (Month / Year) And Reason.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by any previous employers?

Yes No

Were any previous job positions designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes No

To Be Read And Agreed To By Applicant	I authorize you to make sure investigations and inquiries to my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. "I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have right to: Review information provided by current/previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information."
I have Read and Accept The Terms of This Application. This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations. Applicant's will be subject to Pre-Employment drug & alcohol screening if offered employment.

Propane Tank
Gasco Corporate Office
6919 Gogebic St
Three Lakes, WI 54562
800-589-2244
715-546-2244
[email protected]