General Information
First Name:
Middle Name:
Last Name:
Current Address:
City: State: Zip:
Social Security Number:
Home Phone:
Cell Phone:
Other Phone:
DOB:
E-Mail:
How did you hear about our Company?
If Employee Referral, Who?
Highest Grade Completed:
Have you ever served in the armed services?
If yes, please complete the following 3 questions:
Dates of Services:
Branch:
Discharge Status:
List All Driver License/Permit Held in Past Three (3) Years:
State: License: Type: Expiration Date: (mm/dd/yy)
State: License: Type: Expiration Date: (mm/dd/yy)
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Have you ever had any license, permit, or privilege suspended or revoked?
Have you ever been convicted of a felony?
Have you ever been disqualified to drive by federal regulations?
Have you ever tested positive for controll substance?
Have you ever had an alcohol test with a Breath Alcohol Concentrate of 0.04 or greater?
Have you ever refused a required test for drugs or alcohol?
If you answered " yes " to any of the above. please state date, circumstances, and details:
Employment Record (Please List Last 10 Years)
Current/Most Recent Employer:
May we contact your current employer?
Supervisor:
City/State: Telephone:
From: (mm/dd/yy) To: (mm/dd/yy) Pay Rate:
Position Held:
Number of States Driven:
Reason For Leaving:
Tractor Driven: Trailer Pulled:
Were you subject to FMCSRs* while employed?
Was your job designated as a saftey sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR part 40?
Previous Employer #2:
Supervisor:
City/State: Telephone:
From: (mm/dd/yy) To: (mm/dd/yy) Pay Rate:
Position Held:
Reason For Leaving:
Tractor Driven: Trailer Pulled:
Were you subject to FMCSRs* while employed?
Was your job designed as a saftey sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR part 40?
Previous Employer #3:
Supervisor:
City/State; Telephone:
From : (mm/dd/yy) To: (mm/dd/yy) Pay Rate:
Position Held:
Reason For Leaving:
Tractor Driven: Trailer Pulled:
Were you subject to FMCSRs* while employed?
Was your job designed as a saftey sensitive function in any DOT-regulated mode subject to the drug and
alcohol testing requirements of 49CFR part 40?
Previous Employer #4:
Supervisor:
City/State: Telephone:
From: (mm/dd/yy) To: (mm/dd/yy) Pay Rate:
Position Held:
Reason For Leaving:
Tractor Driven: Trailer Pulled:
Were you suject to FMCSRs* while employed?
Was your job designed as a saftey sensitive function in any DOT-regulated mode subject to the drug and
alcohol testing requirements of 49CFR part 40?
Previous Employer #5:
Supervisor:
City/State: Telephone:
From: (mm/dd/yy) To: (mm/dd/yy) Pay Rate:
Position Held:
Reason For Leaving:
Tractor Driven: Trailer Pulled:
Were you subject to FMCSRs* while employed?
Was your job designed as a saftey sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR part 40?
* 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 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in quantity requiring placarding.
Accident Record
Nature of Accident #1
Date: (mm/dd/yy)
Type of Vehicle: Preventable:
Nature of Accident #2
Date: (mm/dd/yy)
Type of Vehicle: Preventable:
Nature of Accident # 3
Date: (mm/dd/yy)
Type of Vehicle: Preventable:
Traffic Convictions
Charge:
Date: (mm/dd/yy)
Location (state) :
If speeding, mph over limit: Penalty:
Charge:
Date: (mm/dd/yy)
Location (state) :
If speeding, mph over limit: Penalty:
Charge:
Date: (mm/dd/yy)
Location (state) :
If speeding, mph over limit: Penalty:
Consent to Run DAC Report:
Additional Jobs and Comments:
Release Statement
Please Read Carefully Before Submitting Application
I authorize you to make such investigations and inquiries of my personal, employment, fincial or medical history and other related matters as may be necessary in arriving at employment decision. (Generally, inquiries reguarding 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 applications. In the event of employment, I understand , also, that I am required to abide by all rules and regulations of the Company.
I understand that information I provide regarding current and/or previous employers maybe used, and those employer(s) will be contacted, for the purpose of investigation my saftey 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 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.
Part I - DOT Drug and Alcohol Release
I authorize, per 49 CFR Part 40, the release of information from my DOT regulated drug and alcohol testing records by the carriers ( company/school) listed below to DAC for thew sole purpose of transmitting such records to the above listed employer. I authorize release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (i) alcohol test 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 regulations; (v) information obtained from previous employers of a drug and alcohol rule violation(s); and (vi) documents, if any, of completion of a return-to-duty process a rule violation.
The information that I have authorized DAC to review involves tests required by DOT. If any carrier (company/school)
listed below furnishes DAC with information concerning items (i) through (iv) above, I also authorize that carrier
(compnay/school) to release and furnish the dates of my negative drug/or tests with results below 0.04 during the three year period and the name and phone number of any substance abuse professional who evaluated me during the past three years.
Part II - Investigative Consumer Report Release
In connection with my application for employment (including contract for services) with the employer named above, I hereby fully release and discharge you and DAC Services, their respective affiliaties, subsidiaries, directors, officers, employees, agents and attorneys thereof, and each of them, and any individual, organization, entity, agency, or other source providing information to above named employer and/or DAC Services from all claims and damages arising out of the summary of rights of the consumer pursuant to the Fair Credit Reporting Act (FCRA), and have also been provided a discloser that an investigative consumer report will be sought pursuant to the FCRA.
By submitting this application, I certify that I have read and fully understand this release, that prior to submitting I was given an opportunity to ask questions and to have those questions answered to my satifactions, and that I executed this release voluntarily and with the knowledge that the information being release could affect my being hired. I further certify that all of the information that I have furnished on this form is true and complete.
I hereby authorize and give my consent to the above company procurement of consumer report(s) (FCRA). If hired or contracted, this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment or contract period. THIS AUTHORIZATION DOES NOT APPLY TO DRUG AND ALCOHOL INFORMATION OBTAINED UNDER PART I.
