Hiland Dairy

Welcome! We are so glad that you are interested in applying for Hiland Dairy! Please fill out the following application in order to have your application submitted for consideration.

Have a wonderful day!

Hiland Dairy Application

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Supplemental Application for D.O.T. Drivers
Employment Record for D.O.T. Drivers
Declaration of Employment Status for D.O.T. Drivers
Clearinghouse Acknowledgement for D.O.T. Drivers

Order Number

EMPLOYMENT APPLICATION

The company is an equal opportunity employer and does not discriminate against any applicant or employee because of race, color, religion, gender, national origin, age, disability, veteran status, citizenship or any other characteristic protected by federal, state or local law.

Applicant Instructions: Individuals who need assistance with any phase of the application process should notify the person who gave them the application to request a reasonable accommodation.

Complete all four pages.
Print clearly; incomplete or illegible applications will not be processed. PLEASE NOTE "NOT APPLICABLE" IF NOT ANSWERING A QUESTION.
Provide only requested information. Failure to do so may result in disqualification of your application.
The EEO Self Identification Form information is being gathered for federal recordkeeping purposes only. The information requested is voluntary and will be kept confidential. An applicant will not be subject to any adverse treatment for refusing to complete the questionnaire.

Email Address *

Last Name *

First Name *

Middle Initial

Today's Date *

Current Address:

Street/PO Box *

City, State Zip *

Prior Address:

Street/PO Box *

City, State Zip *

Phone *

Home Cell Other

Phone

Home Cell Other

Position for which you are applying: *

Are you at least 18 years of age?

18 Years of Age Options

Yes No

Are you legally eligible to work in the United States?

Proof of employment eligibility will be required if hired.

Eligible to Work Options

Yes No

AVAILABILITY: What date can you start?

What date can you start?

What category would you prefer?

Category Options

Full Time Part time Temporary

For which schedules are you available?*

*Reasonable efforts will be made to accommodate sincerely held religious beliefs.

Schedules Available

Weekdays Weekends Evenings Nights Overtime Shift Other

ESSENTIAL JOB FUNCTIONS

Job Description Given

Yes No

Understand Job Functions

Yes No

Able to Perform

Yes No

Have you been given a job description or had the essential functions of the job explained to you? (Job description is below)

Do you understand these essential functions?

After carefully reviewing the job description and physical requirements of the job for which you are applying, are you able to perform the essential functions of the job with or without reasonable accommodation?

PROFESSIONAL LICENSES AND CERTIFICATIONS

Licenses or Certifications Options

Yes No

Do you hold any professional licenses or certifications?

Name of license/certifications

License/certification number

Issuing State

Revoked or Suspended Options

Yes No

Has your license/certification ever been revoked or suspended?

If yes, state the reason(s), date of revocation or suspension, and date of reinstatement: *

REFERENCES: Include only individuals familiar with your work ability. Do not include relatives or names of supervisors listed.

NAME

ADDRESS/PHONE

YEARS KNOWN/RELATIONSHIP

Reference 1

Reference Address/Phone 1

Reference Years Known/Relationship 1

Reference 2

Reference Address/Phone 2

Reference Years Known/Relationship 2

Reference 3

Reference Address/Phone 3

Reference Years Known/Relationship 3

EDUCATION

Please select highest grade completed: *

7 8 9 10 11 12 13 14 15 16 16+

If your school records are under a different name than listed above, please enter that name *

NAME

High School *

CITY/STATE

High School City/State

GRADUATED

Graduated High School

Yes No

DEGREE TYPE

High School Degree Type

College

College City/State

Graduated College

Yes No

College Degree Type

Other

Other City/State

Graduated Other

Yes No

Other Degree Type

By clicking this checkbox, then you verify that you understand the job description as described above. Note: you will be required to sign this document in person. *

I Agree

Date *

PREVIOUS EMPLOYERS

PLEASE NOTE: Your application may not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical. Ask for a phone book or call information if necessary. FOR EMPLOYERS OUTSIDE THE U.S., A CURRENT FAX NUMBER IS MANDATORY.

MOST RECENT EMPLOYER

Currently Working for Employer 1

Yes No

May We Contact 1

Yes No

Are you currently working for this employer?

If yes, may we contact?

Company Name: *

City, State: *

Phone Number: *

Dates Employed: From: *

To: *

Job Title: *

Supervisor: *

Duties: *

Salary: *

Per *

Hour Week Month

Reason for Leaving: *

SECOND MOST RECENT EMPLOYER

Currently Working for Employer 2

Yes No

May We Contact 2

Yes No

Are you currently working for this employer?

If yes, may we contact?

Company Name:

City, State:

Phone Number:

Dates Employed: From:

To:

Job Title:

Supervisor:

Duties:

Salary:

Per

Hour Week Month

Reason for Leaving:

THIRD MOST RECENT EMPLOYER

Currently Working for Employer 3

Yes No

May We Contact 3

Yes No

Are you currently working for this employer?

If yes, may we contact?

Company Name:

City, State:

Phone Number:

Dates Employed: From:

To:

Job Title:

Supervisor:

Duties:

Salary:

Per

Hour Week Month

Reason for Leaving:

FOURTH MOST RECENT EMPLOYER

Currently Working for Employer 4

Yes No

May We Contact 4

Yes No

Are you currently working for this employer?

If yes, may we contact?

Company Name:

City, State:

Phone Number:

Dates Employed: From:

To:

Job Title:

Supervisor:

Duties:

Salary:

Per

Hour Week Month

Reason for Leaving:

DRIVER LICENSE INFORMATION

Valid Driver License Options

Yes No

If the job requires, do you have the appropriate valid driver license?

Name on license

Type

DL #

Issuing State

Moving Violations Options

Yes No

Have you had any moving violations within the last seven years?

If yes, please describe:

CRIMINAL HISTORY

Please note that a "Yes" answer to any of the following questions will not necessarily disqualify you from employment. Factors such as the age and time of the offense, seriousness and nature of the violation, and rehabilitation will be considered when making any employment decisions.

Felony Options

Yes No

Have you ever been convicted of or pleaded guilty to a crime? Do not include convictions that were sealed, erased, annulled or expunged pursuant to a court order.

Please explain any

CERTIFICATION AND RELEASE

I understand that this application form is intended for use in evaluating my qualifications for employment and that this application is not an offer of employment. I further understand that if hired, my employment will be considered "at will" and that my employment may be terminated for any reason, with or without cause or notice, at any time by me or the Company and that this application is not intended to constitute a contract of continued employment.

I certify that the information submitted by me on this application is true and complete. I understand that any false information, misrepresentations or omissions on this application, on other written materials, or provided during any interviews will lead to the rejection of my application or, if I am employed, discipline up to and including termination at the time of false information or omission is discovered.

I understand that any additional testing of job-related skills and for the presence of drugs may be required prior to employment. I also understand that after an offer of employment and prior to reporting to work, I may be required to submit to a medical review and depending on Company policy and the needs of the job. I may be required to complete a medical history form and be examined by a medical professional designated by the company. I also understand that I may not be under the influence of drugs or alcohol during employment and that if Company policy so requires. I may be required to submit to drug and/or alcohol testing at an approved testing facility.

I understand that smoking is prohibited in all indoor areas of the Company's facilities unless designated smoking areas have been established at a particular location in accordance with applicable state and local law.

I authorize the Company and/or its agents, including consumer reporting bureaus, to investigate and verify any of the information provided by me. I authorize my former employers, educational institutions, references and any relevant agencies to provide information to the Company and/or its agents concerning my background and experience. I release the Company and all parties providing information to the Company about my background and experience from any liability whatsoever arising therefrom.

By clicking this checkbox, then you agree to the certification and release as stated. Note: you will be required to sign this document in person. *

I Agree

Date *

NOTICE AND AUTHORIZATION

DISCLOSURE REGARDING BACKGROUND CHECK INVESTIGATION

The "Company" may obtain information about you from a consumer reporting agency for employment purposes. Thus you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, driving record, and/or mode of living and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by Compu-FACT Research, Inc. 1236 Jungermann Rd., Ste H1, St. Peters, MO 63376, (888) 258-0216, or another outside organization. The scope of this disclosure and authorization is all-encompassing, however, allowing Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

ACKNOWLEDGEMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I'm hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested, by Compu-FACT Research, Inc. or another outside organization. I agree that a facsimile ("fax"), electronic or photocopy of this Authorization shall be as valid as the original.

New York & Maine applicants or employees only:

You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly.

Minnesota or Oklahoma applicants or employees only:

Please check this box if you would like to receive a copy of any consumer report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under state law.

California applicants or employees only:

Under section 1786.22 of the California Civil Code, you may view the file maintained on you by Compu-Fact during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at Compu-Fact's offices in person, during normal business hours and on reasonable notice, or by mail. You may also receive a summary of the file by telephone, upon submitting proper identification. Compu-Fact has trained personnel available to explain your file to you, including any coded information. If you appear in person you may be accompanied by one other person, provided that person furnishes proper identification.

Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law.

The following is for identification purposes only to perform the background check and will not be used for any other purposes.

Applicant's Name:

First Name

Middle Name

Last Name

Other Name(s) Used:

First Name

Middle Name

Last Name

Dates You Stopped Using Other Name(s)

Current Address *

City *

State *

Zip Code *

Social Security Number *

Date of Birth *

Drivers License Number *

State Issued *

By clicking this checkbox, then you agree to the notice and authorization as stated above. Note: you will be required to sign this document in person. *

I Agree

Today's Date *

EEOC Self Identification Form

HILAND DAIRY FOODS COMPANY

This information is being gathered for affirmative action under Section 503 of the Rehabilitation Act of 1973. The information requested is voluntary and will be kept confidential. An applicant will not be subject to any adverse treatment for refusing to complete the questionnaire.

The purpose of this section is to assist in monitoring Affirmative Action Programs and to aid in complying with any required Government recordkeeping or periodic reporting. This information is not part of your employment application and will not be considered in the employment/selection process. If you choose to provide the information, please complete the following:

Name:

Job Title

GENDER

Male Female

RACE/ETHNICITY (CHECK ONE)

Are you Hispanic or Latino?

Yes (H) No

Hispanic or Latino

A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race.

If you answered

(AI) American Indian (not Hispanic or Latino). A person having origins in any of the original peoples of North and South American (including Central America), and who maintain tribal affiliation or community attachment.

(A) Asian (not Hispanic or Latino). A persona having origins in any of the original people of the Far East, Southeast Asia, or the Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.

(B) Black or African American (not Hispanic or Latino). A person having origins in any of the black racial groups of Africa.

(PI) Native Hawaiian or Other Pacific Islander (not Hispanic or Latino). A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.

(W) White (not Hispanic or Latino). A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

(2+) Two or More Races (not Hispanic or Latino)

PRE-OFFER INVITATION TO VOLUNTARILY SELF-IDENTIFY PROTECTED VETERANS

Name:

Date

Branch/Plant Location:

Hiland Dairy Foods Company, LLC is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs of Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: 1) disabled veterans; 2) recently separated veterans; 3) active duty wartime or campaign badge veterans; and 4) Armed Forces Service Medal Veterans. Definitions for each classification are listed below.

As a Government contractor subject to VEVRAA, Hiland Dairy Foods Company, LLC requests this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Please assist us with our reporting obligations by selecting the category below as to which you believe you belong.

SELECT YES OR NO

NO: I am not a protected Veteran.

YES: I identify as one or more of the classifications of protected veterans listed below.

- Disabled Veteran: 1) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but 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 for active duty in the U.S. military, ground, naval, or air service.
- Active Duty Wartime or Campaign Badge Veteran: Any 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.
- Armed Forces Services 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.

Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed services, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Services (VETS), toll-free, at 1-866-4-USA-DOL.

Voluntary Self-Identification of Disability

Name:

Date:

Why are you being asked to complete this form?

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you 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, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:

- Autism
- Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
- Blind or low vision
- Cancer
- Cardiovascular or heart disease
- Celiac disease
- Cerebral palsy

- Deaf or hard of hearing
- Depression or anxiety
- Diabetes
- Epilepsy
- Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
- Intellectual disability

- Missing limbs or partially missing limbs
- Nervous system condition for example, migraine headaches, Parkinson's disease, or Multiple sclerosis (MS>
- Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Please check one of the boxes below:

Please check one of the boxes

Yes, I Have A Disability, Or Have A History/Record Of Having A Disability

No, I Don't Have A Disability, Or A History/Record Of Having A Disability

I Don't Wish To Answer

PUBLIC BURDEN STAETMENT: 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.

Supplemental Application for D.O.T. Drivers

Hiland Dairy Foods Company, LLC

1133 East Kearney, Springfield, MO 65803

(417) 862-9311

Applicant Information

First Name *

Middle Name *

Maiden Name (if any)

Last Name *

Current Address *

City *

State *

Zip *

How Long? *

Date of Birth *

Phone # *

Social Security Number *

Addresses for the past three years:

Previous Address

City

State

Zip

How Long?

Previous Address

City

State

Zip

How Long?

Previous Address

City

State

Zip

How Long?

Experience and Qualifications - Driver

Driver Licenses

State *

License No. *

License Type *

Expiration Date *

State

License No.

License Type

Expiration Date

State

License No.

License Type

Expiration Date

Driving Experience

Class of Equipment

Type of Equipment

Dates

Approximately No. of Miles

Straight Truck *

Van, Tank, Flat, Etc.

From

Total

Tractor/Trailer *

Van, Tank, Flat, Etc.

From

Total

Tractor/2 Trailers *

Van, Tank, Flat, Etc.

From

Total

Other *

Van, Tank, Flat, Etc.

From

Total

Accident Record for Past Three (3) Years or More

Dates

Nature of Accident

Fatalities

Injuries

Last Accident

Head-On, Rear-End, Upset, Etc.

Fatalities

Injuries

Previous Accident

Head-On, Rear-End, Upset, Etc.

Fatalities

Injuries

Previous Accident

Head-On, Rear-End, Upset, Etc.

Fatalities

Injuries

Traffic Convictions and Forfeitures for Past Three (3) Years or More (Other than parking violations)

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? *

Yes No

B. Has any license, permit or privilege ever been suspended or revoked? *

Yes No

If the answer to either A or B is yes, write a statement giving details.

Employment Record

NOTE: DOT requires that employment for at least 3 years previous and/or Commercial Driving Experience for the past 10 years be shown. Please list most recent Employer(s) first.

Employer Name *

Address *

Phone *

Supervisor *

Position Held *

From *

To *

Salary *

Reason for Leaving *

Were you subject to 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 requirements of 49 CFR Part 40? *

Yes No

Employer Name

Address

Phone

Supervisor

Position Held

From

Salary

Reason for Leaving

Were you subject to 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 requirements of 49 CFR Part 40?

Yes No

Employer Name

Address

Phone

Supervisor

Position Held

From

Salary

Reason for Leaving

Were you subject to 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 requirements of 49 CFR Part 40?

Yes No

Employer Name

Address

Phone

Supervisor

Position Held

From

Salary

Reason for Leaving

Were you subject to 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 requirements of 49 CFR Part 40?

Yes No

Employer Name

Address

Phone

Supervisor

Position Held

From

Salary

Reason for Leaving

Were you subject to 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 requirements of 49 CFR Part 40?

Yes No

Employer Name

Address

Phone

Supervisor

Position Held

From

Salary

Reason for Leaving

Were you subject to 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 requirements of 49 CFR Part 40?

Yes No

Employer Name

Address

Phone

Supervisor

Position Held

From

Salary

Reason for Leaving

Were you subject to 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 requirements of 49 CFR Part 40?

Yes No

Provide additional experience, if necessary.

Declaration of Employment Status

- This refers to any gaps in employment history -

I understand that I must provide my complete employment history for the past 3 years, and all CDL required employment for the 7 years preceding that. Any gaps in employment longer than 1 month are explained as follows:

From

During this time, I was engaged in the following activity:

In addition:

I was not employed in any company or individual

I was not convicted of any criminal act involving the use of a commercial motor vehicle or while driving a commercial motor vehicle

To Be Read and Signed By Applicant

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 a conditional offer of employment has been extended.) I hereby release employers, schools, health care 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 interviews may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.

I understand information I provide regarding current and/or previous employers may be used, and those employers 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 the previous employer
- Have errors in the information corrected by previous employers and for those previous employers to resubmit 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.

By clicking this checkbox, then you certify this application was completed by you, and that all entries on it and information in it are true and complete to the best of your knowledge. Note: you will be required to sign this document in person.

I certify the information to be true

Date *

DRUG AND ALCOHOL CLEARINGHOUSE

NOTICE TO REGISTER & CONSENT TO PRE-EMPLOYMENT QUERY ACKNOWLEDGEMENT

NOTICE TO DRIVER: The DOT Drug & Alcohol Clearinghouse is a federal database containing information about CDL drivers who have violated the Federal Motor Carrier Safety Administration's (FMCSA's) drug or alcohol regulations in 49 CFR Part 382. Whether you have committed such a violation or not, each motor carrier for whom you drive is required to check whether the Clearinghouse has any information about you, both before employment and annually.

ACKNOWLEDGEMENT

I, , hereby understand that Hiland Dairy Foods Company, LLC is required to conduct a full detailed query of prospective driver's FMCSA's Drug & Alcohol Clearinghouse record, to ensure he or she is eligible to perform safety-sensitive functions.

Hiland Dairy must ensure there is no violation on the prospective driver's record. If there is, the record must also show that the driver has successfully completed the evaluation, referral, treatment, and return-to-duty testing process.

I agree to go to the DOT Drug & Alcohol Clearing house (www.clearinghouse.fmcsa.dot.gov) to register and grant electronic consent to Hiland Dairy within 24 hours of signing this acknowledgement form. Hiland Diary Foods will obtain my full Clearinghouse record. Refusal to provide such consent will result in my removal from consideration in the recruitment process.

By clicking this checkbox, then you agree to the acknowledgement above. Note: you will be required to sign this document in person. *

I agree

Date *