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Applicant Name
*
Date of Application
*
MM slash DD slash YYYY
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.
Position(s) Applied For
*
List your addresses of residency for the past 3 years.
Current Address
*
Phone
*
City
*
State
*
Zip
*
Previous Address(es)
Street
Zip
State
How Long?
Do you have the legal right to work in the United States?
Date (Only answer if applying as a commercial driver)
*
MM slash DD slash YYYY
Can you provide proof of age?
*
Have you worked for this company before?
*
If so, location
Dates
*
From
To
Rate of Pay
*
Position
*
Reason for leaving
*
If not, how long since leaving your last employment?
*
Rate of pay desired
*
Is there any reason you might be unable to preform the essential functions of the job for which you have applied?
*
If yes, explain if you wish
Employment History
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 whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
Employer
Name
Address
City
State
Zip
Contact Person
Phone Number
Date(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Position Held
Salary/Wage
Reason for Leaving
Were You Subject to the FMCSRs† While Employed?
Yes
No
* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), 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 GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Accident Record for the Past 3 Years. If None, Write “None”. (Attach Sheet if More Space is Needed).
Last Accident
MM slash DD slash YYYY
Nature of Accident
Fatalities
Injuries
Hazardous Material Spill
Traffic Convictions for the Past 3 Years other than parking violations.
Location
Date
MM slash DD slash YYYY
Charge
Penalty
Driver licenses or permits held in the past 3 years
State
License No.
Class
Endorsement(s)
Expiration Date
MM slash DD slash YYYY
1. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Yes
No
2. Has any license, permit, or privilege ever been suspended or revoked?
Yes
No
If the answer to either 1 or 2 is yes, please give details:
Driving Experience
Straight Truck
Yes
No
Type of Equipment
Dates
From
To
Approx. No. of Miles
Tractor and Two Trailers
Yes
No
Type of Equipment
Dates
From
To
Approx. No. of Miles
Motor coach – School bus
Yes
No
Type of Equipment
Dates
From
To
Approx. No. of Miles
Other
Type of Equipment
Dates
From
To
Approx. No. of Miles
List states operated in for the Last 5 years
List any trucking, transportation or other experiences that may help you work for this company
List any courses or training that may help you work for this company
Education - Highest grade completed.
High School
9
10
11
12
College
1
2
3
4
TO BE READ AND SIGNED BY THE APPLICANT
This certifies that I have completed this application, and that all entries on it and the information in it are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, financial and other related matters as may be necessary in arriving at an employment decision. I understand that consumer reports may be requested by Hire Right. These reports may include, previous employer verifications, reasons for termination, accidents, driving records, etc. I further understand that such reports may contain information from federal, state or other agencies. I hereby release employer, schools, healthcare providers and other persons from all liability in responding to inquiries and its leases that the company may consider assigning me to. You have the right to review information provided to us by your previous employers and have any errors in such information corrected by your previous employers, as stated in section 391.23(i) of the FMCSRs. I authorize, per 49 CFR Part 40 of FMCSRs the release of information from my DOT regulated drug and alcohol testing records by my previous employers to Hire Right for the sole purpose of transmitting such records to the Company and its representative/agents/clients. I authorize the release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulation; (v) information obtained from previous employers of drug and alcohol rule violation(s); and (vi) documents, if any, of the completion of return-to-duty process following a rule violation. I hereby authorize my worksite employer to submit copies of my current and future drug test results to the Company. This authorization shall expire if and when my worksite employer is no longer a client of the Company. The information I have authorized Hire Right to review involves test required by the DOT. If any carrier/school/company for whom I was previously employed furnishes Hire Right with information concerning items (i) through (vi) above, I also authorize that carrier/school/company to release and furnish the dates of my negative drug and/or alcohol tests with results below 0.04 during the three year period and the name and phone number of any substance abuse professional(s) who evaluated my during the past three years.
Full Name
*
Date
*
MM slash DD slash YYYY
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