Application "*" indicates required fields Step 1 of 11 9% EmailThis field is for validation purposes and should be left unchanged. Black Hawk Waste Disposal & Cedar Valley Recycling and Transfer 811 Dearborn AveWaterloo, IA 50703(319)232-4150 Application Please fill out completely for employment consideration Which company are you applying for?* Black Hawk Waste Disposal Cedar Valley Recycling & Transfer What position are you applying for?* Driver Office Shop Other Name* First Middle Initial Last Current Address*City*State*Zip*Previous Address(Last 3 years)CityStateZipPhone*Email Date of Birth* Availability Part Time Full Time How did you hear about this position?*Someone reached out to me on IndeedI found the ad on IndeedEmployee ReferralWebsite AdvertisementOtherAre you currently employed Yes No Date AvailableWage DesiredHave you worked for Black Hawk Waste/Cedar Valley Recycling before? Yes No What yearAre you at least 18 years of age? Yes No Do you have reliable transportation to/from work. Yes No Do you have a current and valid license to drive? Yes No Education Last School Attended, please do not list CDL Education here.School NameCityStateMajorDiploma or CertificateGraduated Yes No YearList any special training that will help you in this positionMilitary Service Branch of ServiceService Start DateDischarge DateStatus Honorable Discharge Dishonorable Discharge Work History We are required by the department of transportation to send Safety Performance History Records Requests to all current and previous employers for commercial motor vehicle applicants.Company Name*From DateTo DateAddress*CityStateZipYour positionSupervisorPhone*Safety sensitive position (DOT)* Yes No Description of dutiesReason for leavingCompany NameFrom DateTo DateAddressCityStateZipYour positionSupervisorPhoneSafety sensitive position (DOT) Yes No Description of dutiesReason for leavingCompany NameFrom DateTo DateAddressCityStateZipYour positionSupervisorPhoneSafety sensitive position (DOT) Yes No Description of dutiesReason for leaving ReferencesExcluding friends and familyNamePhoneRelationshipNamePhoneRelationshipNamePhoneRelationship License #*State*Expiration Date*Class* Class A Class B Class C Other Do you have a valid medical card* Yes No * You will be expected to provide proof upon being hired.Expiration DateDriving School NameGraduate YearWhat CMV do you have experience drivingCheck all that apply Straight Truck Tractor and Trailer Tractor and Two-Trailer Other Type of Equipment Van Tank Dump Flat Describe {Other}How many years experience with this type of equipmentApproximately how many total miles Have you been involved in any accidents in the last three years, regardless of fault? Yes No List any accidents you were involved in for the last three years, regardless of fault.DateType Head-on Rear-end Single Vehicle Intersection Other Fatalities Yes No Describe the accidentDateType Head-on Rear-end Single Vehicle Intersection Other Fatalities Yes No Describe the accidentDo you have additional accidents to report? Yes No Additional AccidentsPlease list all additional accidents, dates, type, fatalities, and explanations here. Have you had any traffic violations in the past three (3) years, other than parking tickets? Yes No List all traffic violations in the past three years, other than parking tickets.DateLocationChargeDisciplinary ActionNonePenaltyFineDateLocationChargeDisciplinary ActionNonePenaltyFineDateLocationChargeDisciplinary ActionNonePenaltyFineDo you have additional traffic violations? Yes No Additional Traffic ViolationsPlease list all additional traffic violations here.Has your license, permit, or privilege to operate a vehicle ever been suspended, revoked or denied? Yes No If yes, please explain Driver Authorizations Pre-Employment Drug Testing, Drug & Alcohol, Previous Employment, and Driving Record General consent for limited queries of the FMCSA Drug & Alcohol Clearinghouse Black Hawk Waste Disposal will hereafter be described as 'BHW'. Drug & Alcohol Testing As a condition of qualification, a urine sample collection and controlled substance test is required. It is understood that a positive test for controlled substance based on the urinalysis test will medically disqualify an applicant from the operation of a commercial motor vehicle for Black Hawk Waste Disposal/Cedar Valley Recycling & Transfer. Black Hawk Waste Disposal/Cedar Valley Recycling & Transfer reserves the right to use an outside agency to maintain and conduct drug screening. This may include pre-employment, post-accident, random, or reasonable suspicion. Your written authorization will be required for the urinalysis test results to be given to any other parties. Part 40.25j requires Employers to ask Applicants whether he or she has tested positive or refused to test on any Pre-Employment alcohol or drug tests administered by an Employer to which the Applicant/Driver applied, but did not obtain safety sensitive transportation work covered by DOT agency alcohol and drug testing rules during the past two (2) years.During the past two (2) years, have you tested positive on a Pre-Employment alcohol or drug test administered by an Employer in which you applied for, but did not obtain safety sensitive transportation work covered by Department of Transportation (DOT) drug and alcohol testing rules?* Yes No During the past two (2) years, have you refused to test on a Pre-Employment alcohol or drug test administered by an Employer in which you applied for, but did not obtain safety sensitive transportation work covered by Department of Transportation (DOT) drug and alcohol testing rules?* Yes No If you answered yes to either of the questions above, please explain below and provide documentation of your successful completion of the return-to-duty process required by part 40 subpart O. Safety Performance History Records Request & MVR 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. These reports are required by Sections 383, 413, and 391.23 of the Federal Motor Carrier Safety Regulations. General consent for limited queries of the FMCSA Drug & Alcohol Clearinghouse (DACH Authorization) I hereby provide consent to Black Hawk Waste Disposal to conduct a limited query of the FMCSA Commercial Driver’s License Drug & Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I understand that if I refuse to provide consent for Black Hawk Waste Disposal to Conduct a limited query of the Clearinghouse, Black Hawk Waste Disposal will prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations. I further understand that this authorization will be used for a pre-employment query, and for annual queries. Certification: I certify that I have read and understood the above requirements and how it affects my employment with Black Hawk Waste Disposal/Cedar Valley Recycling & Transfer and its subsidiaries and authorize Black Hawk Waste Disposal/Cedar Valley Recycling & Transfer to obtain the information authorized above. Electronic Signatures. Each party agrees that this Agreement and any other documents to be delivered in connection herewith may be electronically signed, and that any electronic signatures appearing on this Agreement or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibilityDriver Applicant's Signature*Date* Criminal Background Check & MVR Authorization Black Hawk Waste Disposal / Cedar Valley Recycling and Transfer, hereafter described as 'BHW/CVR', desires to provide its staff and customers with a reasonably safe and secure environment and to provide reasonable protection for the financial and material assets of the company. It is appropriate in the employment process for the ability to screen persons for positions on the basis of specific criminal conviction records that raise a reasonable doubt as to an individual's fitness for a particular position. This procedure is intended to insure the privacy of individuals while meeting the purposes of conviction record checks. This procedure will be followed when filling vacancies with new hires or internal transfers, in positions which are designated as sensitive. This procedure may also be followed in other situations where its use is reasonably deemed relevant to a specific employment decision. When the use of criminal conviction or MVR records is appropriate, within the scope of the policy stated above, any such information must be reviewed by the General Manager as to its relevance to the specific employment decision to be made. This evaluation shall consider, but not be .limited to, the following factors: Falsification of applicationDate of convictionSubsequent employment recordsLength of company service and work performanceNumber and gravity of conviction(s) and the nature of the work to be performedThe potential opportunity through abuse of work related functions or situations, to cause loss or harm to the staff or to the financial or material property of BHW/CVR. All employees are required to sign this release form allowing BHW/CVR to make a thorough criminal background check and gain access to their Motor Vehicle Report(MVR). Existence of a conviction record will not automatically disqualify the applicant/employee from employment. However, giving false information or omission of information may be grounds for denial of employment, discharge if hired, or termination of current employee. Certification: I hereby affirm that I have supplied complete and correct information to all questions in this application and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that falsification of information on this application could be cause for dismissal at any time after employment. I further authorize BHW/CVR to contact any company or persons mentioned in this application except those marked "No" do not contact. I also understand that in conjunction with my employment application, BHW/CVR may use the services of an outside agency to research and verify the information I have provided. This agency will provide a written report of its findings and may utilize various sources of information it deems appropriate, including but not limited to the searches listed hereafter: Identity, Criminal Records, including Criminal Conviction records, Sexual Offender/Predator, Previous Employment, including current and former employers, Military Records, Professional and Personal References. I give permission to screen, verify, and process all of the above. Applicant's Signature*Social Security Number*Today's Date*Electronic Signatures. Each party agrees that this Agreement and any other documents to be delivered in connection herewith may be electronically signed, and that any electronic signatures appearing on this Agreement or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility
