PERSONAL DATA Name

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410 E SOUTHERN ST PO BOX 316 SUTHERLAND, IA 51058 Sickelka Ag Service provides equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.

PERSONAL DATA Name: ________________________________________________________________ Address: _______________________________________________________________ City: _______________________ State: __________ Zip: ___________ Home Phone: (_____) __________________ Cell Phone: (_____) _________________ E-mail Address: _________________________________________________________ Driver’s License:

Class A CDL Manual Transmission Air Brakes

Issuing State/#: Endorsements: ___________________________

Are you a veteran of military service? YES NO Are you legally eligible for employment in the United States? YES NO Please note the position for which you are applying: _____________________________ EDUCATION & SKILLS High School Diploma or GED? YES NO Years Driving Experience__________ Other education or skills_____________________________________________________ Licenses, certificates, forklift or experience that could help you qualify for this position _____________________________________________________________________________________ ___________________________________________________________________________________________________

Ability to perform light maintenance (oil change, fuel filters, air system, electrical, etc) _____________________________________________________________________________________ _____________________________________________________________________________________

GENERAL EMPLOYMENT QUESTIONS Are you willing to work weekends (Example: Load and leave late Sunday)

YES

NO

Are you available to work long shifts, overtime and/or overnight travel?

YES

NO

Are you able to lift 30lb-50lb bags?

YES

NO

Electronic Log Experience or ability to learn

YES

NO

Which Elog type/brand/system used:

Are you able to perform the essential functions of the position for which you are applying with or without any accommodations? YES NO What accommodations are you requesting? Truck Driver Application

Updated 02/21/2018

WORK EXPERIENCE Company Name: _____________________________ Supervisor:____________________ Address:____________________________City:_____________State:_______Zip:______ Title/Position: __________________________________Phone #: ___________________ Job Description (Equipment Used, Duties, Skills): _________________________________ _________________________________________________________________________ _________________________________________________________________________ Dates: From ___________ To __________ May we contact? YES NO Reason for leaving? ________________________________________________________ Company Name: _____________________________ Supervisor:____________________ Address:____________________________City:_____________State:_______Zip:______ Title/Position: __________________________________Phone #: ___________________ Job Description (Equipment Used, Duties, Skills): _________________________________ _________________________________________________________________________ _________________________________________________________________________ Dates: From ___________ To __________ May we contact? YES NO Reason for leaving? ________________________________________________________ Company Name: _____________________________ Supervisor:____________________ Address:____________________________City:_____________State:_______Zip:______ Title/Position: __________________________________Phone #: ___________________ Job Description (Equipment Used, Duties, Skills): _________________________________ _________________________________________________________________________ _________________________________________________________________________ Dates: From ___________ To __________ May we contact? YES NO Reason for leaving? ________________________________________________________ PERSONAL REFERENCES Name

Address

Phone

_________________________________________________________________________________(

)______-__________

_________________________________________________________________________________(

)______-__________

_________________________________________________________________________________(

)______-__________

SIGNATURE

DATE

The information that you provide on this application is subject to verification. Falsifications or misrepresentations may disqualify you from consideration for employment, or if hired, may be grounds for termination at a later date. With my signature above, I certify that all information on this and all attached pages is true, correct and complete to the best of my knowledge and contains no willful falsifications or misrepresentations. I authorize all former employers to release job-related information they have about me and I release all persons or companies from any liability or responsibility for providing such information. Truck Driver Application

Updated 02/21/2018