If at the above residence less than 3 years, list all residences for the past 3 years:
   Street Address  /  City /  State /  Zip

EDUCATION
Yes   |  No      Did you graduate from High School?   If so, what year? 


What other graduate, business, trade, correspondence, night and/or government
schooling have you had?



What awards have you received?  (School, Safety, US Armed Forces, Others)



Yes   |  No      Have you ever served in the Armed Forces?   
                     What Branch? 


Yes   |  No      Have you ever been convicted of a felony?   If yes, 
please explain in full below.  

  Type of charge  /  Date  /  Where  /  Disposition of court

(Conviction of a crime is not an automatic bar to employment.  All 
circumstances will be considered.)


Yes   |  No      Have you ever been disqualified for violations of Federal Motor 
                     Carrier Safety Regulations?
Explain:



DRIVING EXPERIENCE
                     Class / Type Equipment                 From             To      Approx mileage
Yes   |  No      Straight Truck                 
Yes   |  No      Tractor & Semi-trailor     
Yes   |  No      Twin Trailers                  
Yes   |  No      Other                              

List states operating in for the last five years:



Accident review for past 3 years:
   Date  /  Type  /  Fatalities  /  Injuries



Traffic convictions and forfeitures for thge past 3 years other than 
parking violations:
   Location  /  Date  /  Charge  /  Penalty



List all driver's licenses held in past 3 years:
   State Number  /  Expiration Date  /  Type  /  Restrictions



Yes   |  No      Have you ever had any license, permit, or priviledge to operate a 
motor vehicle denied, revoked or suspended?
If yes, what are the facts and circumstances involved?



Yes   |  No      Do you object to loading/unloading freight?  (Driver applicants only)


List below all employment for the past 15 years, beginning with most recent:
( Include the following:  Name & Mailing Address;  From;  To;  Position; 
  Weekly/MO/TRMO/YrWages;  Reason for leaving;  Supervisor's Name )



What particular abilities and/or skills do you have which you feel would 
help you in the job for which you are applying?



Any relatives in our employ and their relationship to you?



Are you now employed?  If no, how long since leaving last job?



If hired, on what date are you available to begin work?


Yes   |  No      Are you legally eligible for employment in the United States?


What caused you to decide to apply here?

I hereby certify that the facts set forth in my employment application are true and complete to the best of my knowledge and agree that any misrepresentation or concealment of material facts may disqualify me from further consideration for employment and may result in dismissal if discovered at a later date.

I hereby authorize the employers and references listed above to give HENRY Dock Works and/or c.s.HENRY Transfer any and all information concerning my previous employment and any pertinant information they may have, personal or otherwise, and release HENRY Dock Works, Inc./c.s.HENRY Transfer and all such employers and references from all liability for any damages whatsoever in furnishing this information.

If employed, I agree to conform to all HENRY Dock Works/c.s.HENRY Transfer rules and regulations. I also understand and agree that if employed, employment is for an indefinite period of time, and that I have the right to terminate my employment at any time for any reason, as does the company. I agree to submit to a polygraph examination, if requested, except where prohibited by law. I further understand and agree that any modification of this agreement must be in writing and duly executed.