Coles Energy, Inc.

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Full Application – Coles Energy, Inc.

Employment Application

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This field is for validation purposes and should be left unchanged.
Applicant Information
Name*
First Middle Last
Primary Phone*
Emergency Phone*
Email*
Physical Exam Expiration Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Have you resided at the above address for 3 or more years?*
- Yes
- No
Previous Address 1*
Street Address Address Line 2 City State ZIP Code
Live At This Address From Date*
MM slash DD slash YYYY
Live At This Address To Date*
MM slash DD slash YYYY
Previous Address 2*
Street Address Address Line 2 City State ZIP Code
Live At This Address From Date*
MM slash DD slash YYYY
Live At This Address To Date*
MM slash DD slash YYYY
Company Questions
Type of position*
Have you worked for Coles Energy, Inc. previously?*
- Yes
- No
Previous Start Date Working at Coles Energy, Inc.*
MM slash DD slash YYYY
Previous End Date Working at Coles Energy, Inc.*
MM slash DD slash YYYY
Reason for leaving?*
Names of relatives employed by Coles Energy, Inc.
Are you currently employed?*
- Yes
- No
Education
Select highest grade completed*
Name of last school attended*
Last School Address*
Last School State*
Trade School
Did you serve in the military?*
- Yes
- No
General Information
Date of Birth*
MM slash DD slash YYYY

The U.S. Department of Transportation request that driver applicants state their date of birth (391.21 (b) (2)). (The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.)
Have you ever been convicted of a felony?*
- Yes
- No
Have you ever worked for this company under another name?*
- Yes
- No
Other Name*
First Last
Driver Experience and Qualifications
How many states to do you have licenses in?*
License 1 State*
License 1 - No.*
License 1 - Class*
License 1 - Endorsement*
License 1 - Expiration Date*
MM slash DD slash YYYY
License 2 State*
License 2 - No.*
License 2 - Class*
License 2 - Endorsement*
License 2 - Expiration Date*
MM slash DD slash YYYY
License 3 State*
License 3 - No.*
License 3 - Class*
License 3 - Endorsement*
License 3 - Expiration Date*
MM slash DD slash YYYY
License 4 State*
License 4 - No.*
License 4 - Class*
License 4 - Endorsement*
License 4 - Expiration Date*
MM slash DD slash YYYY
Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
- Yes
- No
Has any license, permit, or privilege ever been suspended or revoked?*
- Yes
- No
Have you ever been disqualified for violations of the FMCSR?*
- Yes
- No
Please provide details related to answering yes to the question(s) above*
Driving Experience
Class Of Equipment - 1*
Date From - 1*
MM slash DD slash YYYY
Date To - 1*
MM slash DD slash YYYY
Approx Total Miles - 1*
Class Of Equipment - 2
Date From - 2
MM slash DD slash YYYY
Date To - 2
MM slash DD slash YYYY
Approx Total Miles - 2
Class Of Equipment - 3
Date From - 3
MM slash DD slash YYYY
Date To - 3
MM slash DD slash YYYY
Approx Total Miles - 3
Please select each state you operated in during the last five*
- 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
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
List special courses or training that will help you as a driver
List driving awards held and who awards were presented by
Accident Review for past three years
Date Nature of Accident Fatalities Injuries Tow HM Release
Traffic Convictions/Forfeitures past three years other than parking violations
Location Date Charge Penalty
Controlled Substance & Alcohol
Have you ever tested positive or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT regulations during the past three years.*
- Yes
- No
Employment History
The U.S. Department of Transportation requires that drive applications show all employment for the past three years. Effective July, 1987 they must also show commercial driver employment for the seven years immediately proceeding this year period(391.21(b)(10,(100)). Start with last or current position, including military experience, and work back.
Number of positions you have had in the last three years as well as any commercial driving employment in the last last seven years.
Employer 1
Employer - 1*
Employer Address - 1
Street Address Address Line 2 City State ZIP Code
Employer Primary Phone - 1*
Employer Fax - 1
Supervisor Name - Employer - 1
First Last
Position Held - Employer - 1*
Date From - Employer - 1*
MM slash DD slash YYYY
Date To - Employer - 1*
MM slash DD slash YYYY
Pay Rate - Employer - 1*
Employer - 1 - Were you subject to Federal Motor Safety Regulations?*
- Yes
- No
Employer - 1 - Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?*
- Yes
- No
Employer - 1 - Reason For Leaving*
Employer 2
Employer - 2*
Employer Address - 2
Street Address Address Line 2 City State ZIP Code
Employer Primary Phone - 2*
Employer Fax - 2
Supervisor Name - Employer - 2
First Last
Position Held - Employer - 2*
Date From - Employer - 2*
MM slash DD slash YYYY
Date To - Employer - 2*
MM slash DD slash YYYY
Pay Rate - Employer - 2*
Employer - 2 - Were you subject to Federal Motor Safety Regulations?*
- Yes
- No
Employer - 2 - Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?*
- Yes
- No
Employer - 2 - Reason For Leaving*
Employer 3
Employer - 3*
Employer Address - 3
Street Address Address Line 2 City State ZIP Code
Employer Primary Phone - 3*
Employer Fax - 3
Supervisor Name - Employer - 3
First Last
Position Held - Employer - 3*
Date From - Employer - 3*
MM slash DD slash YYYY
Date To - Employer - 3*
MM slash DD slash YYYY
Pay Rate - Employer - 3*
Employer - 3 - Were you subject to Federal Motor Safety Regulations?*
- Yes
- No
Employer - 3 - Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?*
- Yes
- No
Employer - 3 - Reason For Leaving*
Employer 4
Employer - 4*
Employer Address - 4
Street Address Address Line 2 City State ZIP Code
Employer Primary Phone - 4*
Employer Fax - 4
Supervisor Name - Employer - 4
First Last
Position Held - Employer - 4*
Date From - Employer - 4*
MM slash DD slash YYYY
Date To - Employer - 4*
MM slash DD slash YYYY
Pay Rate - Employer - 4*
Employer - 4 - Were you subject to Federal Motor Safety Regulations?*
- Yes
- No
Employer - 4 - Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?*
- Yes
- No
Employer - 4 - Reason For Leaving*
Employer 5
Employer - 5*
Employer Address - 5
Street Address Address Line 2 City State ZIP Code
Employer Primary Phone - 5*
Employer Fax - 5
Supervisor Name - Employer - 5
First Last
Position Held - Employer - 5*
Date From - Employer - 5*
MM slash DD slash YYYY
Date To - Employer - 5*
MM slash DD slash YYYY
Pay Rate - Employer - 5*
Employer - 5 - Were you subject to Federal Motor Safety Regulations?*
- Yes
- No
Employer - 5 - Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?*
- Yes
- No
Employer - 5 - Reason For Leaving*
Employer 6
Employer - 6*
Employer Address - 6
Street Address Address Line 2 City State ZIP Code
Employer Primary Phone - 6*
Employer Fax - 6
Supervisor Name - Employer - 6
First Last
Position Held - Employer - 6*
Date From - Employer - 6*
MM slash DD slash YYYY
Date To - Employer - 6*
MM slash DD slash YYYY
Pay Rate - Employer - 6*
Employer - 6 - Were you subject to Federal Motor Safety Regulations?*
- Yes
- No
Employer - 6 - Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?*
- Yes
- No
Employer - 6 - Reason For Leaving*
Employer 7
Employer - 7*
Employer Address - 7
Street Address Address Line 2 City State ZIP Code
Employer Primary Phone - 7*
Employer Fax - 7
Supervisor Name - Employer - 7
First Last
Position Held - Employer - 7*
Date From - Employer - 7*
MM slash DD slash YYYY
Date To - Employer - 7*
MM slash DD slash YYYY
Pay Rate - Employer - 7*
Employer - 7 - Were you subject to Federal Motor Safety Regulations?*
- Yes
- No
Employer - 7 - Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?*
- Yes
- No
Employer - 7 - Reason For Leaving*
Employer 8
Employer - 8*
Employer Address - 8
Street Address Address Line 2 City State ZIP Code
Employer Primary Phone - 8*
Employer Fax - 8
Supervisor Name - Employer - 8
First Last
Position Held - Employer - 8*
Date From - Employer - 8*
MM slash DD slash YYYY
Date To - Employer - 8*
MM slash DD slash YYYY
Pay Rate - Employer - 8*
Employer - 8 - Were you subject to Federal Motor Safety Regulations?*
- Yes
- No
Employer - 8 - Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?*
- Yes
- No
Employer - 8 - Reason For Leaving*
Employer 9
Employer - 9*
Employer Address - 9
Street Address Address Line 2 City State ZIP Code
Employer Primary Phone - 9*
Employer Fax - 9
Supervisor Name - Employer - 9
First Last
Position Held - Employer - 9*
Date From - Employer - 9*
MM slash DD slash YYYY
Date To - Employer - 9*
MM slash DD slash YYYY
Pay Rate - Employer - 9*
Employer - 9 - Were you subject to Federal Motor Safety Regulations?*
- Yes
- No
Employer - 9 - Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?*
- Yes
- No
Employer - 9 - Reason For Leaving*
Employer 10
Employer - 10*
Employer Address - 10
Street Address Address Line 2 City State ZIP Code
Employer Primary Phone - 10*
Employer Fax - 10
Supervisor Name - Employer - 10
First Last
Position Held - Employer - 10*
Date From - Employer - 10*
MM slash DD slash YYYY
Date To - Employer - 10*
MM slash DD slash YYYY
Pay Rate - Employer - 10*
Employer - 10 - Were you subject to Federal Motor Safety Regulations?*
- Yes
- No
Employer - 10 - Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR part 40?*
- Yes
- No
Employer - 10 - Reason For Leaving*
To Be Read and Signed by Applicant:
It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

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.
Signature*

Contact Info

3619 East State Route 113
P.O. Box 449
Milan, OH 44846

Phone: 888-327-5955

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Coles Energy

3619 East State Route 113
P.O. Box 449
Milan, OH 44846

Phone: 888-327-5955

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