....since 1954

Harrisonburg and Purcellville, Virginia Terminals

 Loudoun Milk Transportation, Inc.

Food Grade Bulk   Liquid Transport

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Employment Application

Loudoun Milk Transportation is committed to providing equal opportunity employment opportunities to candidates and employees without regard to race, religion, creed, age, sex, height, weight, marital status, disability unrelated to an individual’s ability to perform adequately, national origin citizenship, ancestry, or any other characteristic protected by law.

All Information you submit is sent via encryption through our secure web server and held at our office confidentially under lock and key. Information on Applicants that are not hired at this time will be destroyed after six months.

Personal Information

Title of Position You Are Applying For :

First Name:

Middle Name:

Last Name:

Address:

City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania R hode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Home Phone:

Cell Phone

Fax (optional)

Social Security Number:

E-mail Address:

Best time to contact you within 5 Days of posting

Driver License Information

License Number:

State Issued: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania R hode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Expires:

Date of Birth:

Years Verifiable Tractor Trailer Experience:

Endorsements
Please check all the boxes pertaining to your license.:
	What Is Your Current CDL License Class:	A B C None
	Do You Have A Tanker Endorsement:	YES NO

Safety Record
	Have You Had Any Accidents In The Last 3 Years?:	YES NO
	Have You Had Any Tickets In The Last 3 Years?:	YES NO
	Have You Had A DWI or DUI?:	YES NO
	Have You Ever Been Convicted Of A Felony?:	YES NO
	Have You Ever Had Your License Revoked or Suspended?:	YES NO
	If the answer to ANY question is yes, state details, circumstances, and date:

Employment History

Present Employer:

Company Name:

Address:

City:

State:

Zip Code:

Phone:

Position Held:

Employment Dates: From:       To:

Previous Employer

Previous Employer 1: List Most Recent Previous Employer First 

Company Name:

Address:

City:

State:

Zip Code:

Phone:

Position Held:

Employment Dates: From:   To:

Previous Employer

Previous Employer 2: 

Company Name:

Address:

City:

State:

Zip Code:

Phone:

Position Held:

Employment Dates: From:       To:

Comments: Please indicate here the employment position for which you are applying, whether you would like to work full-time or part-time for us, and any additional restrictions or comments you would like to submit.

I Have Read The Disclaimer Below And Authorize  A Background Check

Yes No

DISCLAIMER

I certify that I personally completed this application and that all of the information is true and correct. I hereby authorize Loudoun Milk Transportation to conduct, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I have completed this application of my own free will and hold Loudoun Milk Transportation harmless of all liability for providing this application for my use. 

     Copyright 2007. Loudoun Milk Transportation, Inc. All Rights Reserved.