Job Application

PERSONAL INFORMATION
Today's Date*
MM slash DD slash YYYY
NAME*
Please provide: First Name, Last Name and Middle Initial.
OHER NAMES USED
Please provide us with any other legal names used, if any.
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Mobile Phone*
Email*

EMPLOYMENT HISTORY
Please list all employment, beginning with present or most recent employer. All information must be completed. Please also upload a file of your resume, if you have one.
Please Upload Your Resume, If You Have One
Max. file size: 50 MB.
Employer Name (Most Recent)
Phone
Location
City State
Job Title
Job Hire Date
MM slash DD slash YYYY
Job End Date
MM slash DD slash YYYY
Name of Supervisor (First/Last)
Job Duties
Please list all job duties in a list format
Reason For Leaving
Employer Name #2
Phone
Location
City State
Job Title
Job Hire Date
MM slash DD slash YYYY
Job End Date
MM slash DD slash YYYY
Name of Supervisor (First/Last)
Job Duties
Please list all job duties in a list format
Reason For Leaving
Employer Name #3
Phone
Location
City State
Job Title
Job Hire Date
MM slash DD slash YYYY
Job End Date
MM slash DD slash YYYY
Name of Supervisor (First/Last)
Job Duties
Please list all job duties in a list format
Reason for leaving
Have you ever been suspended or discharged by any employer for misconduct, poor performance, absenteeism, or tardiness in the last seven years?
- Yes
- No
If yes, please explain the circumstances surrounding the discharge and the approximate date:

EDUCATION
Name of high school
Location
City State
Did you graduate?
- Yes
- No
Year graduated
Name of College, if any
Location
City State
Did you graduate?
- Yes
- No
Year graduated
Subjects studied
Name of Technical or Trade School(s), if any
Location
City State
Year graduated
Did you graduate?
- Yes
- No
Subjects studied
Please tell us about any other training or certifications you have

DRIVER'S LICENSE INFORMATION
Driver's license(s) held within the last three years*
Please provide: STATE, LICENSE NO., CLASS
Commercial drivers must be registered with the FMCSA Clearinghouse in order to provide authorization for a pre-employment full query.
By checking this box, I certify that I am registered with the FMCSA Clearinghouse and will approve any query requests made in regards to the position that I am applying for.
- I agree

OTHER INFO
Do you have any physical conditions which may limit your ability to perform the job applied for?*
- Yes
- No
If yes, what can be done to accommodate your limitations?*
EMERGENCY CONTACT INFO
Please provide information for emergency contacts during work hours:
Name (first/last)
Relationship
Phone
Name (first/last)
Relationship
Phone
It is the policy of Robar Enterprises, Inc., Daily Transit Mix, LLC and AgCon, Inc. to afford equal opportunity for employment training, compensation and promotion to all individuals without regard to race, color, creed, religion, sex (including gender harassment and harassment based on pregnancy, childbirth or related medical condition), age, disability, sexual orientation, veteran status, or any other consideration made unlawful by federal, state or local laws.

PROOF OF EMPLOYMENT ELIGIBILITY WILL BE REQUIRED UPON EMPLOYMENT

PRE-EMPLOYMENT DRUG TESTING POLICY

As a component of the screening process, applicants shall be required to undergo drug and/or alcohol screening. Refusal or failure to submit to drug and/or alcohol screening at the time specified will disqualify applicants for further consideration for employment.

I voluntarily agree to submit to drug and/or alcohol screening as part of my application for employment.
Signature of applicant*
Date*
MM slash DD slash YYYY

APPLICANT'S STATEMENT
I certify that the information I have given on this application is true and complete. I understand that omissions, misrepresentations, or falsifications of information will result in rejection of this application and/or will be sufficient grounds for immediate termination.

I authorize the release of all high school, college and other educational records pertaining to my attendance, course work and other school activities at any educational institute attended by me at any time.

I acknowledge by my signature that my former employer is released from any and all claims, demands or liabilities arising out of or in any way related to the disclosure of any and all information relating to my present and former employment, and I request all current and former employers to supply such information to Robar Enterprises, Inc., Daily Transit Mix, LLC and/or AgCon, Inc. upon its request. Additionally I waive and release Robar Enterprises, Inc., Daily Transit Mix, LLC and/or AgCon, Inc. and its agents from any liability for any action taken due to information provided by any current or former employer.

I agree that, if hired, I will conform to all rules, regulations and procedures of Robar Enterprises, Inc., Daily Transit Mix, LLC and/or AgCon, Inc. I further understand and agree that if I am hired, my employment with Robar Enterprises, Inc., Daily Transit Mix, LLC and or/AgCon, Inc. is for an indefinite period and may, regardless of the time and manner of payment of my wages and salary, be terminated at any time by Robar Enterprises, Inc., Daily Transit Mix, LLC and/or AgCon, Inc. or me, with or without prior notice or warning.

I further understand that this Application for Employment and any policies and procedures communicated or followed by Robar Enterprises, Inc., Daily Transit Mix, LLC and/or AgCon, Inc. during the term of my employment are not intended to be and are not a contract of employment, and that any such policies and procedures may be modified, disregarded or eliminated at any time, with or without notice to me, at the Company's sole discretion.

I understand that this application for employment shall be considered active for a period of time not to exceed 90 days from this date and that if I wish to be considered for employment, beyond that date, I must submit another employment application.
Signature of applicant*
Date*
MM slash DD slash YYYY

FOR COMMERCIAL DRIVER APPLICANT ONLY
This section is reserved only for Commercial Driver Applicants only.
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with ____Robar Enterprises, Inc.____(“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.
AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Robar Enterprises, Inc. (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.

I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Date*
MM slash DD slash YYYY
Signature of applicant*
Full Name (First, MI, Last)*
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49 C.F.R. 383.5.

NOTICE TO ALL APPLICANTS:

Step 1 of 9

PERSONAL INFORMATION

POSITION AND COMPANY APPLYING WITH

EMPLOYMENT HISTORY

EDUCATION

DRIVER'S LICENSE INFORMATION

OTHER INFO

EMERGENCY CONTACT INFO

PROOF OF EMPLOYMENT ELIGIBILITY WILL BE REQUIRED UPON EMPLOYMENT

PRE-EMPLOYMENT DRUG TESTING POLICY

APPLICANT'S STATEMENT

FOR COMMERCIAL DRIVER APPLICANT ONLY

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

AUTHORIZATION