Have you ever been employed by the United States Postal Service? *
Have you had any driving violations in the last 3 years? *
If yes, how many?
Have you had any driving accidents in the last 3 years? (DOT and non-DOT reportable) *
If yes, how many?
Have you ever had a DWI? *
Have you ever had a DUI? *
Have you ever been convicted of a felony? *
Are you on parole, probation, or under suspended sentence for commission of a felony? *
Have you ever pleaded guilty to, or been convicted of a criminal offense? *
If yes, how many years ago?
Within the last THREE years, have you tested positive for a controlled substance, had an alcohol test an alcohol concentration of 0.04 or greater, or refused a required test for drugs or alcohol? *
May we contact your current employer? *
Please list as many previous employers as necessary to provide us with at least 3 years of employment history.
Most recent employer must be provided at minimum.
PLEASE READ BEFORE COMPLETING THIS SURVEY
Employees are treated during employment without regard to race, color, religion, sex, national origin, age, veteran status, disability, or any other protected status.
As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Acton responsibilities where they apply.
The purpose for this Data Survey is to comply with government record keeping, reporting, and other legal requirements. This data is for statistical analysis with respect to the success of the affirmative action program. Periodic reports are made to the government on this information. The completion of this data survey is optional. If you choose to volunteer the requested information, please note that all Data Surveys are kept in a confidential file and are not part of your Application for Employment or personnel file.
SUBMISSION OF THIS INFORMATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.
American Indian/Alaskan Native
Native Hawaiian/ Pacific Islander
Two or more races
Decline to furnish ethnic origin
I am not a protected veteran
I choose not to provide this information
I identify as one or more of the classifications of protected veterans listed in this survey
OMB Control Number 1250-0005
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.1 To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear or any punishment because you did not identity as having a disability earlier.
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, of if you have a history or record of such an impairment or medical condition.
Disabilities include, but are not limited to:
Please check one of the boxes below: * Required but you may delcine
YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON'T HAVE A DISABILITY
I DON'T WISH TO ANSWER
Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
1Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.
Disabled Veteran – (1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or (2) A person who was discharged or released from active duty because of a service-connected disability.
Recently Separated Veteran – Any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval or air service.
Armed Forces Service Medal Veteran – Any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Active duty wartime or campaign badge veteran – A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense.
If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job. The information you submit will be kept confidential, except that (1) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations: (2) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment: and (3)Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.
I understand that this Driver Internet Reference Form is a preliminary application and that if requested I will complete an Alan Ritchey, Inc. Driver Application for Employment. I further understand this Reference Form will be reviewed carefully, but its receipt does not imply that I will be employed.
I certify that I personally completed this application and that all the information is true and correct. By submitting this application I authorize the release of all alcohol and controlled substance testing results pursuant to 382.2413 of the Federal Motors Carriers Safety Regulations and release this company from any and all liability as a result of providing the above information.
For screening purposes: * Pick One
I give my permission for Alan Ritchey, Inc. to contact my current employer.
I do not give my permission for Alan Ritchey, Inc. to contact my current employer until after I have been offered and I have accepted a position
with the Company. I acknowledge that I may be terminated if information is discovered that would have disqualified me for the job if it had been known prior to my employment with Alan Ritchey, Inc.
In connection with my application for employment (including contract for services) with Alan Ritchey, Inc., I understand that consumer reports, which may contain public record information, may be requested from USIS Services, Tulsa, Oklahoma. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc., as well as information pertaining to my character, work habits, and performance. I
further understand that such reports may contain public record information concerning my driving, credit, criminal, and civil records, from federal, state, and other agencies which maintain such records, as well as information from USIS concerning previous driving record requests made by others from such state agencies, and state provided
driving records. In addition, I understand that Alan Ritchey Inc. participates in E-Verify to determine the eligibility of their employees to work in the United States. For more information on E-Verify, please go to http://www.dhs.gov/files/programs/gc_1185221678150.shtm
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY USIS TO FURNISH THE ABOVE-MENTIONED INFORMATION.
I hereby certify that the information provided on this application is accurate to the best of my knowledge and subject to verification by this company. I authorize the company, its affiliates and their representatives to investigate all information given and to secure additional job-related information, if necessary. I authorize an
investigative report to be made whereby information is obtained through personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors or others with whom I am acquainted. I understand and consent to an inquiry that may include information as to my character, general reputation, and
personal characteristics, whichever may be applicable. This information may include, but is not limited to, verification of previous employment and employment references, verification of education including requests for transcripts, credit reports, motor vehicle driving records and criminal reports, etc. I hereby release from all liability or responsibility all persons, companies, organizations or corporations furnishing such information.
I understand that the information I have provided regarding my previous employment may be used, and my prior employers may be contacted for the purpose of investigating my background and safety performance history information as required by §391.23 (d) & (e) of the Federal Motor Carrier Safety Regulations.
Applicant’s signature (typed name) *