Driver Employment Application Driver Application Desired Position * Desired Location * 1. Personal Information Full Name * Email Address Home Phone * Address * Address Address Address City City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip 2. Employment Information Employment Desired * Full-time Part-time Seasonal Do you have the legal right to work in the United States? * Yes No Are you over the age of 18? * Yes No Can you provide proof of age? * Yes No Have you ever worked this company before? * Yes No If yes, where? Dates of Employment with us? Rate of Pay and Position Reason for leaving When will you be able to begin work? How did you hear about us? Have you ever been bonded? * Yes No Name of Bonding Company Have you been convicted of a felony? * Yes No Please explain fully. Conviction of a crime is not an automatic bar to employment. All circumstances will be considered. 3. Employment History Please give accurate, complete full-time and part-time employment record for the past 7 years (if applicable). Start with your present or most recent employer. (If more than 4 employers please list additional employment in text box at end). All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code Applicants to drive a commercial motor vehicle*in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for who the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent.) * Includes vehicles having a GVR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding. † The Federal Motor Carrier Safety Regulations )FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a FVWR of 10,001 pounds or more, (2) is designed or used to transpoirt 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding. Most Recent/Current Employer Position Salary/Wage Dates Employed Telephone Number Contact Person Job Title and Description Reason for Leaving Where you subject to the FMCSRS † while employed? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Previous Employer Most recent/current job Position Salary/Wage Dates Employed Telephone Number Contact Person Job Title and Description Reason for Leaving Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Previous Employer Most recent/current job Position Salary/Wage Dates Employed Telephone Number Contact Person Job Title and Description Reason for Leaving Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Previous Employer Most recent/current job Position Salary/Wage Dates Employed Telephone Number Contact Person Job Title and Description Reason for Leaving Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Please List Addition Positions. Include all necesary information shown above for each position. Attach Resume Drop a file here or click to upload Choose File Maximum upload size: 10MB 4. Education/Skills Do you have a high school diploma, GED, or equivalent? * Yes No Highest Grade Completed (High School) 1 2 3 4 Years Completed (College) 1 2 3 4 Last School Attended City, State ACCIDENT RECORD for Past 3 Years or More (Attach Sheet If More Space Is Needed) If None, Write NONE Please List(Where Applicable): Date; Nature of Accident; Fatalities; Injuries; Hazardous Materials Spill TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE. Please List(Where Applicable): Date; Charge; Penalty Experience and Qualifications - Driver List all driver licenses or permits held in the past 3 years. Please include: State, License Number, Type, Expiration Date Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No Has any license, permit or privilege ever been suspended or revoked? Yes No Please provide details. Do you have driving experience Yes No Please provide details. Please Include: Class of Equipment; Type of Equipment; Dates; Approx. No. of Miles(Total) List states operated in for last five years Show special courses or training that will help you as a driver Which safe driving awards do you hold and from whom? Show any trucking, transportation or other experience that may help in your work for this company List courses and training other than shown elsewhere in this application List special equipment or technical materials you can work with (other than those already shown) 5. Review/Submit Your Application FORM FOR GENERAL EMPLOYMENT In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status. I authorize you to make such investigations and inquires of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) 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 understand, also that I am required to abide by by all rules and regulations of the Company. I understand that information I provide regarding current and/or previous 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(d) and (e). I understand that I have the right to: * Review information provided by previous employers * Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer * 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. Checkboxes * I have read and agree to the above terms* VERIFY INFORMATION ABOVE Once you have verified your Employment History, you please sign below and submit you application. APPLICANT'S DIGITAL SIGNATURE PLEASE READ AND UNDERSTAND THE STATEMENT BELOW BEFORE FINALIZING YOUR APPLICATION: ~ The information I have provided in this Application for Employment is true, correct, and complete. False, incomplete, or misrepresented information of any kind will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination. ~ I authorize the employer to contact an obtain information about me from previous employers, educational institutions, and "references" I provided, and any other party necessary to verify the accuracy of information I disclosed in the application, a related employment resume or a personal interview. To assist in the processing of my application, I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations, or organizations who provide information for this purpose. ~ This application is not an employment agreement. If I accept an offer of employment, I understand the employer may terminate my employment at any time, with or without cause and without prior notice, unless required by law. I understand that no one, other than an executive officer of the employer, has authority to enter into any employment agreement with terms contrary to the foregoing and then only in writing signed by such officer. Type Your Name * Date Signed * Affirmative Action - Voluntary Information Affirmative Action - Voluntary Information: COMPLETION OF INFORMATION BELOW IS VOLUNTARY We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria. To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application. In an effort to comply with requirements regarding government record keeping, reporting, and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated. Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations. I acknowledge that the completion of the below information is voluntary Position(s) applied for Date Applied Referral Source Walk-in Employee Relative School Government Employment Agency Private Employment Agency Advertisement OtherOther Name of Referral Source, Agency, Or Advertisement (If Applicable) Full Name (First, Middle, and Last) Contact Number Address (Street, City, State and Zip) Gender Male Female Please check one of the following Equal Employment Opportunity Identification Groups: Caucasian (not of Hispanic origin) Black or African American (not Hispanic or Latino) Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) Hispanic or Latino American Indian/Alaska Native(not Hispanic or Latino) Asian (not Hispanic or Latino) Two or More Races Veteran/Disabled Status: I am an individual with a disability. I am a special disabled veteran. (A person who is entitled to compensation under laws administered by the Department of Veteran Affairs for a disability.) I am a veteran of the Vietnam Era. (A person who served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released with other than a dishonorable discharge.) I served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized. I am a recently separated veteran. (This applies to any veteran during the one-year period beginning on the date of discharge or release.) I have received the Affirmative Action Voluntary Information form and decline to provide the requested information. Δ