KANSAS ETHANOL LLC


	KE Carriers, LLC Employment Application

Paper Application

First Name

Middle Name

Last Name

Phone

Email

Date of Birth

Social Security #

Date Of Application

Position Applied For

Date Available For Work

Do you have legal right to work in the United Sates?

Current Address

Current Mailing Address

Previous Residency Address

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below.

Current License State

Current License #

Current License Type/Class

Current License Endorsements

Current License Expiration Date

Previous License State

Previous License #

Previous License Type/Class

Previous License Endorsements

Previous License Expiration Date

Previous License State

Previous License #

Previous License Type/Class

Previous License Endorsements

Previous License Expiration Date

List Driving Experience for Straight Truck: Date From & To, Approx Mileage, & Equipment Type (Van, Tank, Flat, Etc.)

List Driving Experience for Tractor & Semi-Trailer: Date From & To, Approx Mileage, & Equipment Type (Van, Tank, Flat, Etc.)

List Driving Experience for Tractor & 2 Trailers: Date From & To, Approx Mileage, & Equipment Type (Van, Tank, Flat, Etc.)

List Driving Experience for Tractor & Tank: Date From & To, Approx Mileage, & Equipment Type (Van, Tank, Flat, Etc.)

List Driving Experience for Other: Date From & To, Approx Mileage, & Equipment Type (Van, Tank, Flat, Etc.)

Accident Record for the Past 3 Years: Check this box if none

Date of Accident

Nature of Accident (Head-on, rear-end, upset, etc.)

# of Fatalities

# of Injuries

Chemical Spills (Y/N)

Date of Accident

Nature of Accident (Head-on, rear-end, upset, etc.)

# of Fatalities

# of Injuries

Chemical Spills (Y/N)

Date of Accident

Nature of Accident (Head-on, rear-end, upset, etc.)

# of Fatalities

# of Injuries

Chemical Spills (Y/N)

Traffic Convictions and Forfeitures for the Past 3 Years (Other Than Parking Violations: Check this box if none

Date Convicted

Violation

State of Violation

Penalty (Forfetied bond, collateral and/or points)

Date Convicted

Violation

State of Violation

Penalty (Forfetied bond, collateral and/or points)

Date Convicted

Violation

State of Violation

Penalty (Forfetied bond, collateral and/or points)

Date Convicted

Violation

State of Violation

Penalty (Forfetied bond, collateral and/or points)

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

Current (Most Recent) Employer Name

Phone

Address

Position Held

From

To

Reason for Leaving

Salary

Explain Any Gaps in Employment (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substancestesting asrequired by 49 CFR, part 40? Yes No

Second (Most Recent) Employer Name

Phone

Address

Position Held

From

To

Reason for Leaving

Salary

Explain Any Gaps in Employment (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substancestesting asrequired by 49 CFR, part 40? Yes No

Third (Most Recent) Employer Name

Phone

Address

Position Held

From

To

Reason for Leaving

Salary

Explain Any Gaps in Employment (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substancestesting asrequired by 49 CFR, part 40? Yes No

High School Name

Course of Study

Years Completed

Graduate		Yes No

Details

College Name

Course of Study

Years Completed

Graduate		Yes No

Details

Other Education Name

Course of Study

Years Completed

Graduate		Yes No

Details

Please list any other qualificationsthat you have and which you believe should be considered.

I have read the information at the bottom of this form and agree

Please type the text in the box.

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to:

• Review information provided by current/previous employers;
• Have errors in the information corrected by previous employers, and for those previous employers to resend 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.

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 more information than that required by the Federal Motor Carrier Safety Regulations.