BWC Companies

Application For Employment

BWC IS A EQUAL OPPORTUNITY EMPLOYER

BWC Excavating L.C. - BWC Industrial Services L.L.C.

Applicant Name	Date of Application
	[mm/dd/yyyy]

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status or veterans status, non-job related disability, or any other protected group status.

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after conditional offer of employment has been extended) I hereby release employers, schools, healthcare 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 understand, also, that I am required to abide by all rules and regulations of BWC Excavating LC., BWC Industrial Services LLC., and Whitters Industrial Services LC. I understand that information I provide regarding current and/or previous 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(d) and (e). I understand that I have the right to:

Review information provided by previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send 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 application is not an employment agreement. If I accept an offer of employment I understand the employer may terminate my employment at any time, with or without cause and without prior notice, unless required by law. I understand that no one, other than one of the employer Partners, has the authority to enter into any employment agreement with terms contrary to the foregoing and then only in writing signed by such officer.

Type Applicant Signature	Date
	[mm/dd/yyyy]

WHEN RETURNING YOUR APPLICATION PLEASE ATTACH A MOTOR VEHICLE REPORT TO IT. THE MOTOR VEHICLE REPORT CAN BE OBTAINED AT THE DRIVERS LICENSE OFFICE. IF A MOTOR VEHICLE REPORT IS NOT ATIACHED THIS CAN DELAY YOUR INTERVIEW PROCESS.

Accident Record

FOR PAST 3 YEARS OR MORE (ATIACH SHEET IF MORE SPACE IS NEEDED) - IF NONE WRITE NONE

Last Accident

Date

[mm/dd/yyyy]

Nature of Accident (Head-On, Rear-End, Upset, Etc.)

Fatalities

Injuries

Hazardous Material Spill

Next Previous Accident

Date

[mm/dd/yyyy]

Nature of Accident (Head-On, Rear-End, Upset, Etc.)

Fatalities

Injuries

Hazardous Material Spill

Next Previous Accident

Date

[mm/dd/yyyy]

Nature of Accident (Head-On, Rear-End, Upset, Etc.)

Fatalities

Injuries

Hazardous Material Spill

Next Previous Accident

Date

[mm/dd/yyyy]

Nature of Accident (Head-On, Rear-End, Upset, Etc.)

Fatalities

Injuries

Hazardous Material Spill

Traffic Convictions and Forfeitures

FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) - IF NONE WRITE NONE. ATTACH A SHEET IF MORE SPACE IS NEEDED

Location	Date
	[mm/dd/yyyy]
Charge	Penalty

Location	Date
	[mm/dd/yyyy]
Charge	Penalty

Location	Date
	[mm/dd/yyyy]
Charge	Penalty

Location	Date
	[mm/dd/yyyy]
Charge	Penalty

Experience and Qualifications -- Driver

LIST All DRIVERS LICENSES HELD IN THE PAST THREE YEARS

State	License Number	Type

Expiration Date	Endorsements
[mm/dd/yyyy]

State	License Number	Type

Expiration Date	Endorsements
[mm/dd/yyyy]

State	License Number	Type

Expiration Date	Endorsements
[mm/dd/yyyy]

State	License Number	Type

Expiration Date	Endorsements
[mm/dd/yyyy]

Have you ever been denied a license, permit or privilege to operate a motor vehicle
Yes No
If yes please explain

Has any license, permit or privilege ever been suspended or revoked
Yes No
If yes please explain

Education

Select highest grade completed	College

Last school attended

Address

City	State	Zip Code

Courses

LIST ANY SPECIAL COURSES THAT WILL HELP YOU AS A DRIVER OR FOR THE POSITION APPLYING FOR

Course	Date
	[mm/dd/yyyy]
Course	Date
	[mm/dd/yyyy]
Course	Date
	[mm/dd/yyyy]

Awards

LIST ANY AWARDS HELD AND WHO PRESENTED BY

Award	Presented By

Award	Presented By

Award	Presented By

Other Qualifications

LIST ANY OTHER QUALIFICATIONS OR TRAINING NOT SHOWN ELSEWHERE ON THIS APPLICATION

Platform Experience and Qualifications

PLATFORM EXPERIENCE AND QUALIFICATIONS -IF NONE WRITE NONE (I.E. LIFT TRUCK ETC.)

Types of Platform	Years of Experience

Use	Training Courses

Types of Platform	Years of Experience

Use	Training Courses

Types of Platform	Years of Experience

Use	Training Courses

References

PLEASE PROVIDE THREE WORK REFERANCES AND TWO NON-WORK REFERANCES

1. Work Reference
Name

Address

City	State	Zip Code

Phone	Years Known

2. Work Reference
Name

Address

City	State	Zip Code

Phone	Years Known

3. Work Reference
Name

Address

City	State	Zip Code

Phone	Years Known

1. Non-Work Reference
Name

Address

City	State	Zip Code

Phone	Years Known

2. Non-Work Reference
Name

Address

City	State	Zip Code

Phone	Years Known

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
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 PULBLIC 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 382.413,391.25 OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS.

TO BE READ AND SIGNED BY THE APPLICANT
This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. I also understand that Bill Whitters Construction conducts pre-employment drug screens and physicals.

Type Applicant Signature	Date

Contact

BWC Main Office
1303 Hickory Hollow Road
Solon, Iowa 52333
Phone: 319.848.2078
Officeadmin@bwcexcavating.com

BWC Employment Application

Link to the bwc employment application pdf Print the BWC Employment Application

Have you worked for this company before?
Yes No
IF YES, Where	Rate of Pay	Per

Date Employed From	Date Employed To
[mm/dd/yyyy]	[mm/dd/yyyy]
Reason for Leaving

Class of Equipment	Type of Equipment
Straight TruckYes No
Date From	Date To
[mm/dd/yyyy]	[mm/dd/yyyy]
Approximate Number of Miles

Class of Equipment	Type of Equipment
Tractor & Semi TrailerYes No
Date From	Date To
[mm/dd/yyyy]	[mm/dd/yyyy]
Approximate Number of Miles

Class of Equipment	Type of Equipment
Tractor - Two TrailersYes No
Date From	Date To
[mm/dd/yyyy]	[mm/dd/yyyy]
Approximate Number of Miles

Class of Equipment	Type of Equipment
Tractor - Three TrailersYes No
Date From	Date To
[mm/dd/yyyy]	[mm/dd/yyyy]
Approximate Number of Miles

Do you have any relatives or friends currently employed with this company?
Yes No
If Yes Who

Is there any reason you may be unable to perform the functions of the job for which you have applied for
Yes No
If yes please explain

1. Employer
Name

Address

City	State	Zip Code

Date Employed From	Date Employed To
[mm/dd/yyyy]	[mm/dd/yyyy]
Position Held	Salary/Wage

Contact Person	Title

Phone

Reason for leaving

Were you subject to the FMCSRS while Employed?
Yes No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol testing requirments of 49 CFR PART 40?
Yes No

2. Employer
Name

Address

City	State	Zip Code

Date Employed From	Date Employed To
[mm/dd/yyyy]	[mm/dd/yyyy]
Position Held	Salary/Wage

Contact Person	Title

Phone

Reason for leaving

Were you subject to the FMCSRS while Employed?
Yes No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol testing requirments of 49 CFR PART 40?
Yes No

3. Employer
Name

Address

City	State	Zip Code

Date Employed From	Date Employed To
[mm/dd/yyyy]	[mm/dd/yyyy]
Position Held	Salary/Wage

Contact Person	Title

Phone

Reason for leaving

Were you subject to the FMCSRS while Employed?
Yes No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol testing requirments of 49 CFR PART 40?
Yes No

4. Employer
Name

Address

City	State	Zip Code

Date Employed From	Date Employed To
[mm/dd/yyyy]	[mm/dd/yyyy]
Position Held	Salary/Wage

Contact Person	Title

Phone

Reason for leaving

Were you subject to the FMCSRS while Employed?
Yes No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol testing requirments of 49 CFR PART 40?
Yes No

5. Employer
Name

Address

City	State	Zip Code

Date Employed From	Date Employed To
[mm/dd/yyyy]	[mm/dd/yyyy]
Position Held	Salary/Wage

Contact Person	Title

Phone

Reason for leaving

Were you subject to the FMCSRS while Employed?
Yes No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol testing requirments of 49 CFR PART 40?
Yes No

6. Employer
Name

Address

City	State	Zip Code

Date Employed From	Date Employed To
[mm/dd/yyyy]	[mm/dd/yyyy]
Position Held	Salary/Wage

Contact Person	Title

Phone

Reason for leaving

Were you subject to the FMCSRS while Employed?
Yes No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol testing requirments of 49 CFR PART 40?
Yes No

Class of Equipment
Motorcoach - School Bus
(More Than 7 Passengers)Yes No
Date From	Date To
[mm/dd/yyyy]	[mm/dd/yyyy]
Approximate Number of Miles

Class of Equipment
Motorcoach - School Bus
(More Than 15 Passengers)Yes No
Date From	Date To
[mm/dd/yyyy]	[mm/dd/yyyy]
Approximate Number of Miles

Position(s) applying for
	Part Time Full Time Temporary

Primary Contact #	Cell Phone #

Are you permitted to work in the U.S.
Yes No

Class of Equipment
Other

Date From	Date To
[mm/dd/yyyy]	[mm/dd/yyyy]
Approximate Number of Miles

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