Barry's Paint Shop Employment Application

Because you may be asked to drive company or customer vehicles and to have the ability to do so safely and legally, therefore a completed DRIVER QUESTIONAIRE is required for verification and to validate this application.

Do you hold a valid PA driver's license? *YesNo

FOR NON-EXPERIENCED OR WITH LIMITED EXPERIENCED APPLICANTS: Due to the high costs of job training for repairing today’s complex vehicles, you may be asked to sign a Non-Compete Agreement.

In an effort to give our customers exceptional service and dependability, we depend heavily on each other to work as a team.

High School

Name

City

Years Completed

Major/Subject

GPA

College

Name

City

Years Completed

Major/Subject

GPA

Graduate School

Name

City

Years Completed

Major/Subject

GPA

List any certificates earned or in progress, and/or any additional training programs not included in your formal education.

List any Professional Affiliations to which you belong (please do not list activities which would indicate age, sex, color, race, creed, national origin, religion, marital status, sexual orientation, political belief, or disability):

List any other skills you have relevant to the job:

Previous Job Experiences

List your current or most recent employment first. Include work related internships, military and volunteer work.

Previous Job

Company Name *

City/State *

Phone *

Position Held *

Date Employed From: *

Date Employed To: *

May we contact your employer? *YesNo

Salary: *

Per *

Supervisor's Name & Title *

What will this employer say was the reason you left their company: *

How much notice did you give this employer you were leaving their company? *

Professional References

Reference

Name *

Title *

Professional Relationship

Phone *

Company *

I hereby authorize this Company to contact any of the companies I have listed above regarding my previous employment and the professional references I have given.

Initials of Applicant: *

I understand I may be required to sign a confidentiality, restrictive covenant, and a Conflict of interest statement.

Initials of Applicant: *

I understand I must provide satisfactory documents to establish my identity and right to work in the United States if I am offered a position with this Company, and that failure to provide this evidence will result in the termination of my employment.

I release and agree to hold harmless any individual, company, business institution or government agency from all liability with regard to furnishing information to this Company. I agree to release and hold harmless this Company from all liability with respect to the receipt of such information.

I certify that the information I have furnished on this application form is true and complete. I understand that if any misrepresentation has been made by me verbally or in writing, any offer of employment made to me may be withdrawn or my subsequent employment with this Company may be terminated.

Commercial Driver Questionnaire

We already have you personal information, so all you need to fill out is the following.

Prior State and Operators's Number If Less Than 3 Years

Date first licensed or Date of Permit

Driver's Auto Insurance Company

Commercial Driver's License?

WARNING: An incorrect answer, intentional or not, to any question below may jeopardize continuing coverage. If the answers to any of the following are ‘‘Yes,’’ give details in space provided.

(a) Had any auto insurance refused, cancelled or expired in the past 5 years? or been excluded or restricted on a policy in the past 5 years?

OHIO ONLY: Had any auto insurance refused, cancelled or expired for:

(1) Material misrepresentation in application or in submission of claims?

(2) Suspension, revocation or expiration of operator’s license of named insured or principal operator?

(b) Been required to file evidence of financial responsibility in the past 5 years?

(c) Had their driver’s license or driving privileges revoked or suspended in the past 5 years? (Give date and reason in the additional details box).)

(d) Received a ticket for speeding, a PBJ (PJC in NC), or any other vehicle code violation within the past 5 years?(If “Yes,” give date and description of violation(s). If speeding, include your actual speed and the speed limit.)

(e) Ever receive any felony convictions? Give date, description and penalty.

(f) Had a physical or mental impairment or disability or other medical infirmity? Identify any such condition (e.g., heart, diabetes, epilepsy, hearing, sight or limb loss, back condition or other medical infirmity), its duration and treatment obtained and/or medication prescribed. *

(g) Had any comprehensive losses (deer, fire, glass breakage, theft, etc.) in the past 5 years?

(h) While driving any motor vehicle, commercial or personal, been involved in an accident during the past 5 years?Describe all accidents regardless of who was at fault under Other Pertinent Information)

(i) FOR MD ONLY: Refused to submit to a chemical test or been given probation before judgment for an alcohol violation in the past 3 years?

(NOTE FOR DC ONLY: Question (a) not applicable. For questions (b), (c),(d), (g), (h) & (i), ask for 3 year record only.) (NOTE FOR MD ONLY: For Questions 3 (a), (b), (c), (d), (g), (h) & (i) ask for 3 year record only.) (NOTE FOR WI ONLY: Question 3(f) not applicable.)

Details for "Yes" answers:0 / 375

5. Does driver take home any company autos on a regular basis?If yes, what vehicle(s)? Answer in the Other Pertinent Information - "Truck", "Car", "Van"

6. Does driver have any restrictions on license?If yes, please list them as "Other Pertinent Information"

7. Were MVRs/CLUEs ordered on any/all drivers?

Other Pertinent Information*Vehicles taking home regularly. *List driver’s previous experience driving types of commercial vehicles insured and any safety courses completed. *List any driver license restrictions.0 / 375

DC APPLICANT(S): WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NY APPLICANT(S) (Fraud Warning):WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.

OHIO APPLICANT(S): Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

PA APPLICANT(S): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

TN & VA APPLICANT(S): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

WV APPLICANT(S): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

OTHER APPLICANT(S): Any person who knowingly files an application containing any false, incomplete or misleading information, may be subject to criminal and/or civil penalties.

I have read all the above *YesNo

Date of Form Submission *

Applicant's Signature/Commercial Driver Signature *

I certify that I have given true and complete answers to the above questions.You have my permission to obtain a copy of my motor vehicle driving record for purposes of determining my eligibility for coverage under this policy.

Job Application

Personal Information

Position Desired

Because you may be asked to drive company or customer vehicles and to have the ability to do so safely and legally, therefore a completed DRIVER QUESTIONAIRE is required for verification and to validate this application.

FOR NON-EXPERIENCED OR WITH LIMITED EXPERIENCED APPLICANTS: Due to the high costs of job training for repairing today’s complex vehicles, you may be asked to sign a Non-Compete Agreement.

In an effort to give our customers exceptional service and dependability, we depend heavily on each other to work as a team.

Education

Skills

Previous Job Experiences

List your current or most recent employment first. Include work related internships, military and volunteer work.

Professional References

I hereby authorize this Company to contact any of the companies I have listed above regarding my previous employment and the professional references I have given.

I understand I may be required to sign a confidentiality, restrictive covenant, and a Conflict of interest statement.

I understand I must provide satisfactory documents to establish my identity and right to work in the United States if I am offered a position with this Company, and that failure to provide this evidence will result in the termination of my employment.

I release and agree to hold harmless any individual, company, business institution or government agency from all liability with regard to furnishing information to this Company. I agree to release and hold harmless this Company from all liability with respect to the receipt of such information.

I certify that the information I have furnished on this application form is true and complete. I understand that if any misrepresentation has been made by me verbally or in writing, any offer of employment made to me may be withdrawn or my subsequent employment with this Company may be terminated.

Commercial Driver Questionnaire

We already have you personal information, so all you need to fill out is the following.

WARNING: An incorrect answer, intentional or not, to any question below may jeopardize continuing coverage. If the answers to any of the following are ‘‘Yes,’’ give details in space provided.

Has Driver:

OHIO ONLY: Had any auto insurance refused, cancelled or expired for:

(NOTE FOR DC ONLY: Question (a) not applicable. For questions (b), (c),(d), (g), (h) & (i), ask for 3 year record only.) (NOTE FOR MD ONLY: For Questions 3 (a), (b), (c), (d), (g), (h) & (i) ask for 3 year record only.) (NOTE FOR WI ONLY: Question 3(f) not applicable.)

Please Read

OHIO APPLICANT(S): Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

TN & VA APPLICANT(S): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

WV APPLICANT(S): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

OTHER APPLICANT(S): Any person who knowingly files an application containing any false, incomplete or misleading information, may be subject to criminal and/or civil penalties.

Job Application

Personal Information

Position Desired

Because you may be asked to drive company or customer vehicles and to have the ability to do so safely and legally, therefore a completed DRIVER QUESTIONAIRE is required for verification and to validate this application.

FOR NON-EXPERIENCED OR WITH LIMITED EXPERIENCED APPLICANTS: Due to the high costs of job training for repairing today’s complex vehicles, you may be asked to sign a Non-Compete Agreement.

In an effort to give our customers exceptional service and dependability, we depend heavily on each other to work as a team.

Education

Skills

Previous Job Experiences

List your current or most recent employment first. Include work related internships, military and volunteer work.

Professional References

I hereby authorize this Company to contact any of the companies I have listed above regarding my previous employment and the professional references I have given.

I understand I may be required to sign a confidentiality, restrictive covenant, and a Conflict of interest statement.

I understand I must provide satisfactory documents to establish my identity and right to work in the United States if I am offered a position with this Company, and that failure to provide this evidence will result in the termination of my employment.

I release and agree to hold harmless any individual, company, business institution or government agency from all liability with regard to furnishing information to this Company. I agree to release and hold harmless this Company from all liability with respect to the receipt of such information.

I certify that the information I have furnished on this application form is true and complete. I understand that if any misrepresentation has been made by me verbally or in writing, any offer of employment made to me may be withdrawn or my subsequent employment with this Company may be terminated.

Commercial Driver Questionnaire

We already have you personal information, so all you need to fill out is the following.

WARNING: An incorrect answer, intentional or not, to any question below may jeopardize continuing coverage. If the answers to any of the following are ‘‘Yes,’’ give details in space provided.

Has Driver:

OHIO ONLY: Had any auto insurance refused, cancelled or expired for:

(NOTE FOR DC ONLY: Question (a) not applicable. For questions (b), (c),(d), (g), (h) & (i), ask for 3 year record only.) *(NOTE FOR MD ONLY: For Questions 3 (a), (b), (c), (d), (g), (h) & (i) ask for 3 year record only.) *(NOTE FOR WI ONLY: Question 3(f) not applicable.)

Please Read

OHIO APPLICANT(S): Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

TN & VA APPLICANT(S): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

WV APPLICANT(S): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

OTHER APPLICANT(S): Any person who knowingly files an application containing any false, incomplete or misleading information, may be subject to criminal and/or civil penalties.

(NOTE FOR DC ONLY: Question (a) not applicable. For questions (b), (c),(d), (g), (h) & (i), ask for 3 year record only.) (NOTE FOR MD ONLY: For Questions 3 (a), (b), (c), (d), (g), (h) & (i) ask for 3 year record only.) (NOTE FOR WI ONLY: Question 3(f) not applicable.)