Employment Application | Harrison Brothers Paving

We are always looking to add talented and experienced individuals to our team!

To apply for employment with Harrison Brothers Paving, please complete the below application in its entirety.

Upon receipt of your application, we will review to see if it meets the criteria for any open positions. If so, you will be contacted for an interview. Processing times may vary, but please allow a minimum of 5 business days before calling to follow up on an application.

Applicant Information
Full Name*
First Middle Last
Phone*
Email*
Social Security #*
Date of Birth*
Month
Day
Year
Date Available for Work*
MM slash DD slash YYYY
Desired Position*
Desired Salary*
Are you a citizen of the United States?*
- Yes
- No
If not, are you authorized to live and work in the U.S.?
- Yes
- No
Have you ever been employed by this organization before?*
- Yes
- No
If yes, list dates of employment
Applicant Residency
Please provide the address(es) you've lived at for the past 3 years.
Current Address*
Street Address Address Line 2 City State ZIP Code
Have you lived at this address less than 3 years?*
- Yes
- No
Previous Address*
Street Address Address Line 2 City State ZIP Code
Have you lived at another address within the past 3 years?*
- Yes
- No
Previous Address 2*
Street Address Address Line 2 City State ZIP Code
Have you lived at another address within the past 3 years?*
- Yes
- No
Previous Address 3*
Street Address Address Line 2 City State ZIP Code
License Information
Driver's License State*
Driver's License Number*
Type/Class*
Endorsements*
Expiration Date*
Drivers License and Medical Certificate*
Please upload a copy of the front and back of your current drivers license, along with your medical certificate (if applicable). Allowed file types are .jpg, .jpeg, .png, .pdf and must be 4mb or less.
Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 4 MB, Max. files: 4.
Driving Experience
Class of Equipment*
Check all that apply.
- Straight Truck
- Tractor & Semi-Trailer
- Tractor & Tanker
- Other
Straight Truck Type*
Approximate Number of Miles (Total)*
Date From*
MM slash DD slash YYYY
Date To*
MM slash DD slash YYYY
Tractor & Semi-Trailer Type*
Approximate Number of Miles (Total)*
Date From*
MM slash DD slash YYYY
Date To*
MM slash DD slash YYYY
Tractor & Tanker Type*
Approximate Number of Miles (Total)*
Date From*
MM slash DD slash YYYY
Date To*
MM slash DD slash YYYY
Other (Please Describe)*
Approximate Number of Miles (Total)*
Date From*
MM slash DD slash YYYY
Date To*
MM slash DD slash YYYY
Accident Record
Have you been involved in a motor vehicle accident in the past 3 years?*
- Yes
- No
Accident History*
(Click the + button to add a new row)
Date Nature of Accident (head-on, rear-end, etc.) # of Fatalities # of Injuries Chemical Spills (Y/N)
Traffic Convictions & Forfeitures
Have you had any traffic convictions or forfeitures in the past 3 years?*
- Yes
- No
Conviction History*
(Click the + button to add a new row)
Date Convicted Violation State of Violation Penalty (Forfeited bond, collateral, and/or points)
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*
- Yes
- No
If Yes, Please Explain*
Has any license, permit, or privilege ever been suspended or revoked?*
- Yes
- No
If Yes, Please Explain*
Previous Employment
The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards(attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.
Current Employer (Most Recent)
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Held
Dates Employed
From To
Reason for Leaving?
Salary
Explain any gaps in employment
Include Month/Year & Reason
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
- Yes
- No
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?
- Yes
- No
Did you need to list another employer?*
- Yes
- No
Previous Employer (Second Most Recent)
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Held
Dates Employed
From To
Reason for Leaving?
Salary
Explain any gaps in employment
Include Month/Year & Reason
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
- Yes
- No
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?
- Yes
- No
Did you need to list another employer?
- Yes
- No
Previous Employer (Third Most Recent)
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Held
Dates Employed
From To
Explain any gaps in employment
Include Month/Year & Reason
Reason for Leaving?
Salary
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
- Yes
- No
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?
- Yes
- No
Did you need to list another employer?
- Yes
- No
Previous Employer (Fourth Most Recent)
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Held
Dates Employed
From To
Explain any gaps in employment
Include Month/Year & Reason
Reason for Leaving?
Salary
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
- Yes
- No
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?
- Yes
- No
Education
Please enter each school that you attended, including high school, trade schools, and/or college.
Education*
(Click the + button to add a new row)
School Name Location Years Completed Did You Graduate? (Y/N) Details
Other Qualifications
Please list any other qualifications that you have and which you believe should be considered.
Acknowledgement
I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to:
• Review information provided by current/previous employers;
• Have errors in the information corrected by previous employers, and for those previous employers to resend 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.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.
Digital Signature:*

Typing your First Name, Middle Initial, and Last Name will act as your digital signature.
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Applicant Information

Applicant Residency

License Information

Driving Experience

Accident Record

Traffic Convictions & Forfeitures

Previous Employment

Education

Acknowledgement

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Date	Nature of Accident (head-on, rear-end, etc.)	# of Fatalities	# of Injuries	Chemical Spills (Y/N)

Date Convicted	Violation	State of Violation	Penalty (Forfeited bond, collateral, and/or points)

From	To

From	To