APPLICATION FOR EMPLOYMENT

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APPLICATION FOR EMPLOYMENT

DATE
First Name Middle Name
Last Name Phone
Current Address
Street City
State Zip Code
*If at the above residence less than three years, list below all residences for the past three years. Attach a separate sheet if necessary.
Street City
State Zip Code
Street City
State Zip Code
Position Applying For:
Who referred you?
Have you worked for this company before? Dates
Where? Position
Reason for leaving
Have you ever worked for this company before under another name? If so, what name?
Names of any relatives employed by this company:
EDUCATION
Highest grade completed: College
GENERAL
Have you ever been convicted of a felony? Please explain
Date
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.
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DRIVER EXPERIENCE & QUALIFICATION

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DRIVER EXPERIENCE & QUALIFICATION

Date of Birth: The U.S. Department of Transportation requires that driver applicants state their date of (month/date/year) birth (391.2 (b)(2))
Social Security Number:

Licenses

Drivers Licenses held in the past 3 years must be shown.
State License No. Class Endorsements Expiration Date
When did you obtain your CDL?
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:
C. Have you ever been disqualified for violations of Federal Motor Carrier Safety Regulations? Yes: No:
If you have answered, "yes" to A, B, C please explain
Class of Equipment Type of Equipment(van,tank,flat,etc.) Date From To Approximate Total Mileage
Straight Truck
Tractor & Semi-Trailer
Twin Trailers
Other
List states operated in during last five years:
List special courses or training that will help you as a driver
List driving awards held and who awards were presented by

ACCIDENT REVIEW

Accidents for the past 3 years must be shown. Attach a separate sheet of paper if necessary.
Dates Nature of Accident Injuries Fatalities
Last Accident
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TRAFFIC CONVICTIONS AND FORFEITURES- NON CMV

For the past 3 years other than parking. Attach a separate sheet if of paper if necessary.
Location Date Charge Penalty

TRAFFIC CONVICTIONS AND FORFEITURES/ DOT INSPECTIONS- CMV

For the past 2 years other than parking including all DOT inspection clean or otherwise. Attach a separate sheet if of paper if necessary.
Location Date Charge Penalty
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Employment Record

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Employment Record

Employer: Supervisor's Full Name
Full Address:
Zip: Phone
Position Held:
From: To:
Salary:
Reason for leaving:  
Please explain:
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode subject to the Drug and Alcohol testing requirements of 49CFR part 40?
Employer: Supervisor's Full Name
Full Address:
Zip: Phone
Position Held:
From: To:
Salary:
Reason for leaving:  
Please explain:
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode subject to the Drug and Alcohol testing requirements of 49CFR part 40?
Employer: Supervisor's Full Name
Full Address:
Zip: Phone
Position Held:
From: To:
Salary:
Reason for leaving:  
Please explain:
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode subject to the Drug and Alcohol testing requirements of 49CFR part 40?
Employer: Supervisor's Full Name
Full Address:
Zip: Phone
Position Held:
From: To:
Salary:
Reason for leaving:  
Please explain:
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode subject to the Drug and Alcohol testing requirements of 49CFR part 40?
Employer: Supervisor's Full Name
Full Address:
Zip: Phone
Position Held:
From: To:
Salary:
Reason for leaving:  
Please explain:
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode subject to the Drug and Alcohol testing requirements of 49CFR part 40?
Employer: Supervisor's Full Name
Full Address:
Zip: Phone
Position Held:
From: To:
Salary:
Reason for leaving:  
Please explain:
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode subject to the Drug and Alcohol testing requirements of 49CFR part 40?
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DRIVER’S RIGHTS

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DRIVER’S RIGHTS

DRIVER’S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23

Drug Screen Results


  • Have you 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 two years?
  • If you answered yes, to the above question, can you provide proof that you’ve successfully completed the DOT return-to-duty requirements?

Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.

  • (a)(1) An inquiry into the driver’s driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator’s license or permit during those three years; and
  • (a)(2) An investigation of the driver’s employment record during the preceding three years.
  • (b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver’s employment begins and be retained in compliance with 391.51.
  • (c) Replies to the investigations of the driver’s safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver’s employment begins. This goes into effect after October 29, 2004.
  • (d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.
  • (e) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.

Drivers have the following rights:

  • The right to review information provided by previous employers
  • The right to have errors in the information corrected by the previous employer and for that previous employer to resend the corrected information to the prospective employer.
  • The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver’s request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver’s safety performance history.

CFR Part 40.25(j) requires the employer to ask any applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, we must not use the employee to perform safety-sensitive functions, until and unless the potential employee provides documentation of successful completion of the return-to-duty process. (See section 40.25(b)(5) and (e)).

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APPLICANT MUST READ AND SIGN

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APPLICANT MUST READ AND SIGN

APPLICANT MUST READ AND SIGN

I certify that I have read and understood all of this employment application. It is agreed and understood that the employer or his agents may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons named herein form all liability for any damages on account of furnishing such information.

I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I capable of performing tasks which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the results of a physical examination and drug test.

I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reasons.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508; I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal. If hired, I agree to abide by all the rules and policies of the employer.

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

Signature Date
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ADDITIONAL EMPLOYMENT HISTORY INFORMATION

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ADDITIONAL EMPLOYMENT HISTORY INFORMATION

Employer: Supervisor's Full Name
Full Address:
Zip: Phone
Position Held:
From: To:
Salary:
Reason for leaving:  
Please explain:
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode subject to the Drug and Alcohol testing requirements of 49CFR part 40?
Employer: Supervisor's Full Name
Full Address:
Zip: Phone
Position Held:
From: To:
Salary:
Reason for leaving:  
Please explain:
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode subject to the Drug and Alcohol testing requirements of 49CFR part 40?
Employer: Supervisor's Full Name
Full Address:
Zip: Phone
Position Held:
From: To:
Salary:
Reason for leaving:  
Please explain:
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode subject to the Drug and Alcohol testing requirements of 49CFR part 40?
Employer: Supervisor's Full Name
Full Address:
Zip: Phone
Position Held:
From: To:
Salary:
Reason for leaving:  
Please explain:
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode subject to the Drug and Alcohol testing requirements of 49CFR part 40?
Employer: Supervisor's Full Name
Full Address:
Zip: Phone
Position Held:
From: To:
Salary:
Reason for leaving:  
Please explain:
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode subject to the Drug and Alcohol testing requirements of 49CFR part 40?
Employer: Supervisor's Full Name
Full Address:
Zip: Phone
Position Held:
From: To:
Salary:
Reason for leaving:  
Please explain:
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode subject to the Drug and Alcohol testing requirements of 49CFR part 40?

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