You must answer every question. If any question does not apply to you, answer with
Not Applicable (NA).
In compliance with local, state, and federal equal employment opportunity laws, qualified applicants are considered for all positions without regard to age, race, color, sex, sexual orientation, marital status, veteran status, or non-job related disability. Please advise in advance if you need any type of special accommodation to complete this application form or need to take any pre-employment test.
If you were at above address less than three years, list your previous address.
§391.21 (b)(10) A list of the names and addresses of the applicant's employers during the 3 years preceding the date the application is submitted, together with the dates he/she was employed by, and his/her reason for leaving the employ of, each employer; (b)(11) For those drivers applying to operate a commercial motor vehicle as defined by Part 383 of this subchapter, a list of the names and addresses of the applicant's employers during the 7 year period preceding the 3 years contained in paragraph (b)(10) of this section for which the applicant was an operator of a commercial motor vehicle, together with the dates of employment and the reasons for leaving such employment. (Attach another sheet if more space is needed)
A total of 10 years work history is required. All gaps in time must be shown.
Current or most recent employer
Previous Employee Pre-Employment Drug & Alcohol Testing Statement
4. If the answer is yes to the above questions, provide details, attach second sheet if necessary
6. If yes to any of the above questions, please provide proof that you have successfully completed the SAP Evaluation, recommended treatment, return to duty testing and follow up testing. (Attach another sheet if necessary)
Accident record for past 3 years or more (attach sheet if more space is needed)
Traffic convictions and license forfeitures for the last 3 years (other than parking violations))
Driving Experience: (Class of Equipment)
In connection with my application to the company, I understand that the Fair Credit Reporting Act, Public Law 91-508 & 104-208 requires that I be advised that routine inquiry may be made during the company’s initial or subsequent processing which will provide applicable information concerning character and general reputation. I also understand that investigative background inquiries as required by the Federal Motor Carrier Safety Regulations 391.23 may be made on me including previous employers, along with schools, consumer credit, criminal convictions, motor vehicle records, and other reports.
These reports will include information as to my character, work habits, performance, education, compensation, and experience along with reasons for termination of employment from previous employers. Furthermore, I understand that the company may be requesting information from various federal, state, and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil, and other experiences as well as claims involving me in the files of insurance companies. I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for doing so. This authorization and consent shall be valid in original, fax, email, other electronic form, or copy form.
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 this application was only completed by me, and that all entries on it and the information I have furnished on this application form is true and complete. I authorize you to make such investigations and inquiries of my personal, employment, financial, or medical history. (Generally, inquiries regarding medical history will be made only and if 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 false or misleading information given in my application or in interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the Company if a conditional offer of employment is made.
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 49CFR 391.23. I understand that pursuant to 49CFR 391.23 I have a right to: Review information provided by current previous employers; have errors in the information corrected by previous employers and 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.
PRE-EMPLOYMENT DRUG AND ALCOHOL SCREENING CONSENT
I UNDERSTAND AND CONSENT TO
SUBMIT TO A PRE-EMPLOYMENT URINALYSIS DRUG AND BREATH ACOHOL SCREEN TEST.
I ALSO UNDERSTAND THAT EMPLOYMENT WITH THIS IS COMPANY IS DEPENDENT ON THE
NEGATIVE RESULTS OF SUCH TEST.