Name: (First - Middle - Last) Address: (Street - City - State - Zip) Date of Birth: (Month / Day / Year) SSN: (xxx-xx-xxxx) Telephone #: Cell Phone #: Email Address: Referred By: How did you hear about us? Driver referral Newspaper Online Truck on the Road Roadside Sign Other Have you ever been employed by this company in the past? YesNo If yes, please explain Fair Credit Reporting Act Disclosure Statement In accordance with the provision of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations. Driver Notification This notice serves to fulfill the requirements of 49 CFR Part 391.23(i). Each motor carrier must notify each driver, who is regulated by the Department of Transportation, of their rights regarding investigative information that will be provided to a prospective employer. Drivers have: 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 re-send 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. Past Pre-Employment Drug & Alcohol Testing Question In accordance with 49 CFR Part 40.25(j) the employer is required to ask the employee: Have you ever tested positive 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 testing rules during the past two years? YesNo Previous addresses for the past 3 years: 1.(Street - City - State - Zip Code) 2.(Street - City - State - Zip Code) 3.(Street - City - State - Zip Code) 4.(Street - City - State - Zip Code) 5.(Street - City - State - Zip Code) 6.(Street - City - State - Zip Code) 7.(Street - City - State - Zip Code) Current drivers license: (State - License No. - Class/Type - Expiration Date) Driver licenses for the past 3 years: 1.(State - License No. - Class/Type - Expiration Date) 2.(State - License No. - Class/Type - Expiration Date) 3.(State - License No. - Class/Type - Expiration Date) 4.(State - License No. - Class/Type - Expiration Date) 5.(State - License No. - Class/Type - Expiration Date) 6.(State - License No. - Class/Type - Expiration Date) 7.(State - License No. - Class/Type - Expiration Date) Have you ever had your license, permit or driving privileges suspended or revoked? YesNo If yes, please explain Driving experience: Class A (Semi-Tractors): (# of Years & Months Operated) Class B (Straight Trucks/Dump Trucks, Etc.): (# of Years & Months Operated) Class B (Buses/Passenger Vehicles): (# of Years & Months Operated) Types of trailers transported/operated Dry Van Reefer Flatbed Double/Triples Tanker Pneumatic Dump Trailer Hopper Intermodal Auto Hauler Specialized Hot Shot Other (please list): Motor vehicle accidents for past 3 years Date - Description of the Accident - # of Fatalities - # of Injuries Description of the Accident # of Fatalities # of Injuries Violations of motor vehicle laws or ordinances for the past 3 years (please do not list parking violations) Violations Date of violations   Violations Date of violations Have you ever been convicted of a Felony, DUI or DWI? YesNo If yes, please explain Are currently working for any other employers, full time or part time? YesNo If yes, please explain Past Employment or Lease Record (List ALL past employment for the last 3 years and ALL DOT regulated past employers for the past 10 years) Past Employer Name: Address: City: State: Phone Number: Fax Number: Position Held: From: To: Equipment Driven: Reason for Leaving: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR�s while employed by this employer? YesNo       Past Employer Name: Address: City: State: Phone Number: Fax Number: Position Held: From: To: Equipment Driven: Reason for Leaving: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR�s while employed by this employer? YesNo       Past Employer Name: Address: City: State: Phone Number: Fax Number: Position Held: From: To: Equipment Driven: Reason for Leaving: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR�s while employed by this employer? YesNo       Past Employer Name: Address: City: State: Phone Number: Fax Number: Position Held: From: To: Equipment Driven: Reason for Leaving: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR�s while employed by this employer? YesNo       Past Employer Name: Address: City: State: Phone Number: Fax Number: Position Held: From: To: Equipment Driven: Reason for Leaving: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR�s while employed by this employer? YesNo       Past Employer Name: Address: City: State: Phone Number: Fax Number: Position Held: From: To: Equipment Driven: Reason for Leaving: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR�s while employed by this employer? YesNo       Past Employer Name: Address: City: State: Phone Number: Fax Number: Position Held: From: To: Equipment Driven: Reason for Leaving: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR�s while employed by this employer? YesNo       Past Employer Name: Address: City: State: Phone Number: Fax Number: Position Held: From: To: Equipment Driven: Reason for Leaving: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR�s while employed by this employer? YesNo       Past Employer Name: Address: City: State: Phone Number: Fax Number: Position Held: From: To: Equipment Driven: Reason for Leaving: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR�s while employed by this employer? YesNo       Past Employer Name: Address: City: State: Phone Number: Fax Number: Position Held: From: To: Equipment Driven: Reason for Leaving: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR�s while employed by this employer? YesNo       Past Employer Name: Address: City: State: Phone Number: Fax Number: Position Held: From: To: Equipment Driven: Reason for Leaving: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR�s while employed by this employer? YesNo             In Case of Emergency Please Contact: (Name - Relationship - Telephone No.)

To be read and signed by the applicant

This certifies that this application and any additional past employer records have been completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. I understand that if employed or leased, any misstatement or omission of fact on this application shall be considered cause for dismissal. I authorize investigation of all statements contained in this application for employment or lease as may be necessary in arriving at a decision.

Date of Application:

This is a Rehire

I agree to the background check authorization as detailed below

______________________________________________ Applicant's Signature

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