I, the undersigned, hereby authorize R & R Pipeline, Inc. or its insurance agency, Kernan Insurance Agency, Inc., or
its assigns, to obtain copies of a motor vehicle report pertaining to me for employment purposes and for use in rating
and/or underwriting insurance for which the above-named employer may apply, and any renewal thereof.
Employer 1
Start Date
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Role/Title
Reason for Leaving
Employer 2
Start Date
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Reason for Leaving
Employer 3
Start Date
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Role/Title
Reason for Leaving
References
Commercial Driver Experience and Qualifications
Straight Truck
Start Date
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Equipment Type
Approx # of Miles
Tractor/Semi Trailer
Start Date
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Equipment Type
Approx # of Miles
Tractor/Two Trailers
Start Date
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Equipment Type
Approx # of Miles
Accident Record for Past 3 Years or More
Last Accident
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Nature of Accident
Next Most Previous Accident
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Nature of Accident
Next Most Previous Accident
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Nature of Accident
Traffic Convictions and Forfeitures for Past 3 Years or More
Last Traffic Conviction/Forfeiture
Date
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Locations
Next Most Recent Traffic Conviction/Forfeiture
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Locations
Next Most Recent Traffic Conviction/Forfeiture
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Locations
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Has any license, permit or privilege ever been suspended or revoked?
Criminal Background Check Authorization
A criminal background check is required for employment. This check into official public records will determine the existence
or non-existence of any record of criminal convictions. Federal and state law provides that certain positions of employment
within the State of Ohio are unavailable to individuals who have plead guilty and or been convicted of criminal conduct, based
on the nature of the criminal violations and/or the type of position being sought. Prior criminal convictions do not automatically
preclude employment.
Full Name (Last, First, M.I.)
Previous Names Used Within 10 Years
Full Name
Date Changed
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Full Name
Date Changed
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Full Name
Date Changed
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Date of Birth
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Please provide complete addresses for U.S. residences during the last 10 years
Address 1
Start Date
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End Date
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Address 2
Start Date
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End Date
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Address 3
Start Date
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End Date
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Address 4
Start Date
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End Date
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Authorization
R&R Pipeline, Inc. maintains the right to conduct, either through state employees or through a third party,
a criminal background check of any employee or job applicant. None of the information provided on this form
will be used to discriminate against any applicant or employee on the basis of race, color, national origin, sex,
sexual orientation, genetic information, religion, age, disability or military status.
By signing this form, you authorize R&R Pipeline, Inc. and/or it's designated third party to conduct a criminal
background check. In addition, you acknowledge that any false or misleading statement, omission or failure to
disclose information may disqualify you from employment or, if employed, may result in dismissal.
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand
that if employed, falsified statements on this application shall be grounds for dismissal.
I authorize invesigation of all statements contained herein and the references and employers list above to give R & R Pipeline, Inc.
any and all information concerning my previous employement and any pertinent information they may have; personal or
otherwise. I release R & R Pipeline, Inc. from all liability for any damages that may result from utilization of such information.
I also understand and agree that no representative of R & R Pipeline, Inc. has any authority to enter into any agreement for
employment for any specified time or to make any agreement contrary to the foregoing unless it is in writing and signed by
an authorized company representative.
I hereby authorize R & R Pipeline, Inc. or it's insurance agency, Kernan Insurance Agency, Inc., or its assigns, to obtain copies
of a motor vehicle report pertaining to me for employment purposes, and for use in rating and/or underwriting insurance for
which R & R Pipeline, Inc. may apply and any renewal thereof.
Upload Resume
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