** Please fill out entire application COMPLETELY – Must sign and date on last page **
Please list three professional references
EMPLOYMENT HISTORY
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.
DRIVING HISTORY - COMMERCIAL AND PERSONAL
List ALL traffic convictions, and forfeitures for the past 3 years (other than parking violations):
APPLICANT INFORMATION
Are you 21 years of age or older:
Do you have the legal right to work in the United States?
Have you ever worked for this company?
Can you perform the essential duties required by this job, with or without a reasonable accommodation?
LICENSE INFORMATION
No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21).
I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.
PREVIOUSLY HELD LICENSES (OTHER STATES, OTHER TYPES, ETC.)
RESIDENCY – PREVIOUS THREE (3) YEARS
Attach additional sheet if more space is needed
CURRENT
PREVIOUS
EDUCATION
Did you graduate?
Did you graduate?
Did you graduate?
1st REFERENCE
2nd REFERENCE
3rd REFERENCE
START WITH CURRENT / MOST RECENT EMPLOYER - MINIMUM 3 YEARS
Compensation Method:
May we contact your previous employer?
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
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 ?
START WITH CURRENT / MOST RECENT EMPLOYER - MINIMUM 3 YEARS
Compensation Method:
May we contact your previous employer?
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
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?
START WITH CURRENT / MOST RECENT EMPLOYER - MINIMUM 3 YEARS
Compensation Method
May we contact your previous employer?
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
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?
IF YOU NEED TO PROVIDE MORE EMPLOYERS, PLEASE ASK FOR AN ADDITIONAL PAGE
1. Driving History
If Yes : (Leave if No )
2nd
3rd
List all motor vehicle accidents applicant involved in the past 3 years:
If Yes : Explain , ( Leave if No )
THE FOLLOWING QUESTIONS MUST BE ANSWERED:
Have you ever been disqualified under Federal Motor Carrier Safety Regulations guidelines?
Have you ever been convicted or are any charges pending for driving while under the influence of alcohol, a narcotic drug, amphetamines or methamphetamines or derivatives thereof?
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 agency drug and alcohol testing rules during the past three years?
Has any license, permit, or privilege to operate a motor vehicle issued to you ever been denied, revoked, or suspended? YES NO IF YES, EXPLAIN:
DRIVING EXPERIENCE
EXPERIENCE
MILITARY SERVICE
TO BE READ AND SIGNED BY APPLICANT
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.
I agree that any action or suit against the Company arising out of my employment or termination of employment, including, but not limited to, claims arising under State or Federal civil rights statutes, must be brought within 180 days of the event giving rise to the claims or be forever barred. I waive any limitation periods to the contrary
I understand that if I am hired by the company and the information listed below is not provided, it can result in a delay of the processing of my payroll check.
* A copy of your current driver’s license and medical card
* Form W-4
* Payroll preference (direct deposit/paper check)
* I-9 verification form w/ID documents
REFERRAL
WERE YOU REFERRED TO OUR COMPANY BY A CURRENT EMPLOYEE?