Drive With Us

Please complete the application below.

DRIVER’S RIGHTS TO REVIEW BACKGROUND CHECK - Dear Applicant:

Per FMCSR 391.21(d) Before an application is submitted, the motor carrier shall inform the applicant that the information he/she provides for the work history may be used, and the applicant's prior employers may be contacted, for the purpose of investigating the applicant's safety performance history information. The prospective motor carrier must also notify the driver in writing of his/her due process rights as specified in § 391.23(i) regarding information received as a result of these investigations. You the applicant have the following rights: (i) The right to review information provided by previous employers; (ii) The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective motor carrier; (iii) 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.

Driver Applicant Printed Name

Acceptance of the Rights to Review Background Check Statement Above

I understand and accept the statement above

Date Accepted

Your Information

First Name

Middle Initial

Last Name

Phone Number

Email Address

Your Current Street Address

City

State

Zip Code

Years in Location

If at the above residence for less than 3 years, list below all residences for the past 3 years:

Date of Birth

Social Security Number

In Case of Emergency Notify

Emergency Contact Phone

Have you applied with us before?

If yes, when?

Have you ever worked for this company under another name?

Name you previously worked under

Are you applying as a (check appropriate)

company driver owner operator

Ever applied with this company before

If yes, when?

Are you currently employed?

If not employed, how long since leaving your last employment?

Date you are available to start work?

How long are willing to be away from home?

List states operated in last 5 years

List safe driving awards and who presented by

How much home time will you need when you return?

How many miles or hours are you expecting per week?

How much do you expect to make per week (gross)?

Have you ever been convicted of a crime?

Are there any pending charges against you?

(A conviction does not automatically bar you from employment) If yes, explain for each entry: 1) Is it a conviction or pending charge? 2) Date of conviction or upcoming hearing, and 3) State in which convicted/charged.

Select highest grade level completed.

Last School Attended

School Address

List special courses or training that will help you as a driver

EMPLOYMENT RECORD

Complete all data for EACH last employer COMPLETELY. The U.S. Department of Transportation requires that the driver applicants show all employment for the past three years. Effective July 1, 1987, they must also show commercial driver employment for the seven years preceding this three year period. Sec.391.21 (b) (10) (11). Account for any gaps in employment between employers.

Last Employer

Employer Name

Phone Number

Address

City

State

Zip Code

Position held

Date started

Date ended

Type of equipment driven

Areas driven in

Were you regulated by FMCSA during this job?

Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?

Reasons for leaving

Second Last Employer

Employer Name

Phone Number

Address

City

State

Zip Code

Position held

Date started

Date ended

Type of equipment driven

Areas driven in

Were you regulated by FMCSA during this job?

Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?

Reasons for leaving

Third Last Employer

Employer Name

Phone Number

Address

City

State

Zip Code

Position held

Date started

Date ended

Type of equipment driven

Areas driven in

Were you regulated by FMCSA during this job?

Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?

Reasons for leaving

Fourth Last Employer

Employer Name

Phone Number

Address

City

State

Zip Code

Position held

Date started

Date ended

Type of equipment driven

Areas driven in

Were you regulated by FMCSA during this job?

Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?

Reasons for leaving

Driver Experience and Qualification

LICENSES List all licenses held in the last 3 years

State

License Number

Type/Endorsements

Expiration Date

State

License Number

Type/Endorsements

Expiration Date

State

License Number

Type/Endorsements

Expiration Date

Do you currently hold more than one valid license?

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Has any license, permit or privilege ever been suspended or revoked?

Have you ever tested positive or refused a pre-employment drug test for a motor carrier that didn’t hire you in the last (3) three years?

Have you ever been disqualified for violations of the Federal Motor Carrier Safety Reg’s (including Drug & Alcohol)?

If answered Yes to any of the above questions, please give details:

Accident Review for past 3 years: (List none or NA if clean record)

Date of Accident

City

State

Number of Fatalities

Number of Injuries

Nature of Accident

Date of Accident

City

State

Number of Fatalities

Number of Injuries

Nature of Accident

Motor Vehicle Laws & Ordinances for the past 3 years other than parking violation: (List none or NA if clean record)

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

Experience

Class of Equipment

Type

Date From

Date To

Class of Equipment

Type

Date From

Date To

Applicant: Read and sign before submitting this application.

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty and reason for non-consideration or subsequent dismissal if hired or denial of authorization to drive. It is also agreed and understood that the motor carrier and his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his/her furnishing such information. I authorize the motor carrier to access the FMCSA Pre-Employment Screening Program (PSP) to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand that nothing contained in this application or in the granting of any interview or a road test is intended to create an employment contract between this company and myself, for either employment, authorization to drive, or for the providing of any benefits. I agree to furnish such additional information that may be necessary and complete such examinations as may be required to complete my application file including but not limited to a pre-employment negative urine test and successful completion of a human performance evaluation including a Department of Transportation Physical. No promises regarding employment or authorization to drive have been made to me, and no such promises exist unless specifically made by this Company in writing. It is agreed and understood that if qualified, hired, or contract started, I may be on a probationary period during which time I may be disqualified without recourse. I understand employment or authorization to drive with this carrier is on an “at-will” basis that allows me to quit, be fired, or lease

Applicant's Printed Name

I accept and certify

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.

DISCLOSURE STATEMENT

Applicant: Read and sign before submitting this application. By this document, Motor Carrier Name discloses to you that a consumer report, including an investigative report containing information as to your character, general reputation, personal characteristics, driving record, and mode of living may be obtained as part of a background investigation as part of the Motor Carrier Name’s driver qualification process. Should an investigation consumer report be requested you have the right to demand a complete and accurate disclosure of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act. Please sign below to signify receipt of the foregoing disclosure.

Applicant's Printed Name

Please check to signify receipt of the foregoing disclosure