Town & Country Supply Association is an equal opportunity employer and does not discriminate in any aspect of employment on the basis of race, color, religion, sex, pregnancy, sexual orientation, national origin, marital status, age, ancestry, veteran status, physical or mental disability, or any other legally protected status.Please exclude any information, which may indicate your race, color, religion, sex, pregnancy, sexual orientation, national origin, marital status, ancestry, veteran status, physical or mental disability, or any other legally protected status.









    Current Address: Include City, State and Zip



    Previous Address if less than 3 years: Include City, State and Zip



    *** 3 years of previous addresses required per DOT regulations. If more space is needed, please attach additional sheets ***

    Education Information

    School Name – High School





    College





    Technical





    If you did not graduate from high school, did you complete the G.E.D.?



    DRIVING EXPERIENCE

    Straight Truck





    Tractor & Semi – Trailer





    Tractor & Two – Trailer





    Tank





    Transport





    Passenger





    Other





    Employment Record
    Any gaps in employment must be explained

    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.









    Were you subject to the FMCSR’s while employed by this employer?

    Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and
    controlled substances testing requirements as required by 49 CFR part 40?

    Employment Record #2









    Were you subject to the FMCSR’s while employed by this employer?

    Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and
    controlled substances testing requirements as required by 49 CFR part 40?

    Employment Record #3









    Were you subject to the FMCSR’s while employed by this employer?

    Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and
    controlled substances testing requirements as required by 49 CFR part 40?

    *FMCSR – Federal Motor Carrier Safety Regulations
    Experience and Qualifications – Other




    TO BE READ AND SIGNED BY APPLICANT

    This certifies that this application was completed by me, and that all entries on it are true and complete to the best of my knowledge.



    Town & Country Supply Association Corporate Office
    18 8th Ave.
    P O Box 367
    Laurel, Montana 59044

    Tel: (406) 628-6314
    Fax: (406) 628-7895
    Email: info@tandcsupply.com

    PROPANE ORDERS & INFORMATION
    Tel: (406) 628-6314

    GAS OR DIESEL ORDERS & INFORMATION
    Tel: (406) 628-6314

    TOWN & COUNTRY SUPPLY ASSOCIATION LOCATIONS