* = Required Information

Application For Employment

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, OR NON-JOB RELATED DISABILITY.

Address for the past three years:


Yes No
Yes No
Yes No
Yes No
Yes No

Employment History

List employers in reverse order, beginning with the most recent.

LIST EVERY JOB YOU HAVE HAD IN THE PAST TEN YEARS
BE SURE TO INCLUDE A VALID ADDRESS AND PHONE NUMBER.
IF UNEMPLOYED OR SELF-EMPLOYED, PLEASE LIST WITH DATES.
THERE CANNOT BE ANY TIME GAPS IN THIS 10 YEARS HISTORY

Yes No

Employer

Dates Employed

Yes No
Yes No
Add more ...
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE


TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)



EDUCATION
1 2 3 4
5 6 7 8
1 2 3 4
DRIVER'S LICENSE



Yes No
Yes No
Driving Experience
CLASS EQUIPMENT (STRAIGHT TRUCK)

CLASS EQUIPMENT (TRACTOR / SEMI-TRAILER)

CLASS EQUIPMENT (TRACTOR / TWO TRAILERS)

CLASS EQUIPMENT (OTHER)

OTHER EXPERIENCE AND QUALIFICATIONS
TO BE READ AND SIGNED BY APPLICANT
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. I authorize you to take such investigations and inquiries of my personal, employment, financial, and medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer at 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 that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the company.
CERTIFICATION OF COMPLIANCE WITH DRIVER'S LICENSE REQUIREMENTS

NOTICE TO CARRIERS: The requirements in Part 383 of the Federal Motor Carrier Safety Regulations apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transpons hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements which you, as a driver, must comply. These requirements are in effect as of July 1, 1987. They are as follows:

1) You, as a commercial vehicle driver, may not possess more than one license. The only exception is if a state requires you to have more than one license. This exception is allowed until January 1, 1990. If you currently have more than one license, you should keep the license from your state of residence and return the additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen or destroyed, you should close your record by notifying the state of issuance that you no longer want to be licensed by that state. 2) Sections 392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking); you must report it to your employing motor carrier and the state that issued your license within 30 days.
DRIVER CERTIFICATION
I HEREBY CERTIFY THAT 1 HAVE READ AND UNDERSTAND THE ABOVE REQUIREMENTS AND THAT THE FOLLOWING LICENSE IS THE ONLY ONE THAT 1 WILL POSSESS.

Request for Check of Driving Record

I hereby authorize you to release the following information to (Prospective Employer) for the purpose of investigation as required by section 391.23 of the Federal Motor Carrier Safety Regulations. You are hereby released from any and all liability which may result from furnishing such information.

  1. IN ACCORDANCE WITH THE PROVISIONS OF SECTION 604 OF THE FAIR CREDIT REPORTING ACT, PUBLIC LAW NO.91-508, I HEREBY CERTIFY THAT THE INFORMATION REQUESTED BELOW WILL BE USED FOR A "PERMISSIBLE PURPOSE" AS DEFINED IN THE ACT, AND THAT THE INFORMATION RECEIVED WILL BE USED FOR NO TO HER PURPOSE.
  2. I FURTHER CERTIFY THAT IF THE APPLICANT NAMED BELOW IS DENIED EMPLOYMENT BASED UPON THE INFORMATION RECEIVED, WILL IDENTIFY THE SOURCE OF THE REPORT IN ACCORDANCE WITH SECTION 615(A) OF THE FAIR CREDIT REPORTING ACT.

THE FOLLOWING NAMED PERSON HAS MADE APPLICATION WITH OUR COMPANY FOR THE POSITION OF DRIVER. AS IN ACCORDANCE WITH SECTION 391.23, FEDERAL DEPARTMENT OF TRANSPORTATION REGULATIONS, PLEASE FURNISH THE UNDERSIGNED WITH THE APPLICANT'S DRIVING RECORD FOR THE PAST THREE YEARS.


Past Employment Background Check

The person named above has applied to this company for employment. This applicant lists your firm as past employer. Please complete the following items:

DOT Regulated Driver Non-DOT Regularized Driver
Drug and Alcohol Inquiry

If the above applicant was employed as a driver with your company. Department of Transportation regulation section 382.405 (f) and (h) require that you provide the following information:

Prospective employer did not provide signed release from driver ($40.321(b)). Therefore, drug/alchol information cannot be provided. Under DOT drug and alcohol testing requirements for the past 3 years:

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

In providing this information, any drug or alcohol testing information obtained from previous employers under $40.25 or other applicable DOT regulations is included.

If any of the above questions were answered yes, please provide the following:
Safety Performance History
There is no safety performance history to report.
Straight Truck Tractor-Semi Trailer Bus Cargo Tank
Doubles/Triples
Driver did not operate a motor vehicle.
Discharged Registration Lay Off Military Duty
Accidents


No accident register data for this driver.
Enclosed is other accident information pursuant to the employer's internal policies for retaining minor accident information ($391.23 (d)(2)(ii))
Applicant Consent and Release
I do hereby authorize my previous employer to release information from my drug and alcohol records in accordance with dot regulation 49 CFR PART 40, SECTION 40.25. I also authorize release of all other records of employment including job performance to motor carrier consultants inc. in connection with my application for employment. I hereby release my former employers from any and all liability of any type as a result of providing the above requested information.
Driver Data Sheet

FMCSA Regulation $395.86(2) states that mo1or carriers, when using a driver for the first time or intermittently, shall obtain trom the driver a signed statement giving the total time on duty during the immediately preceding 7 days and the time at which the driver was last relieved from duty prior to beginning work for the motor carriers.

Instructions: In the grid below, write the date and hours you worked, driving or not, for the past seven days. Write your total hours in the "TOTAL" column.

Day 1

Day 2

Day 3

Day 4
Day 5
Day 6
Day 7
I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at: on
Drug, Alcohol, and (Private) Contraband Policy For CDL Drivers Employed By

If there are any questions regarding the above stated drug and alcohoł palicy, you may contact your company representative, CHRIS RIYERS @ 251-219-7558 or Motor Carrier Consultants at 251-433-4111. I, understand and agree to abide by the above requirements and statement as a condition of employment.

Determination that Driver Applicant/Currently Employed Driver Is Fit for Duty

Prior to releasing driver for said examination, The Company requests them to sign a consent form. This consent form will apply to any D.0.T. required drug/alcohol screen performed while driver is employed by The Company.

Consent Form

Voluntary Submission for Physical Examination, Breath/Saliva Analysis, (when performed under the guidelines specified in CFR 49,3382.303] and/or Urine Analysis and the Release of Said Results.

I, voluntarily agree to undergo a physical examination, including a urine test and/or breath/saliva test (when performed under the guidelines specified in CFR 49, S4) by a doctor, medical center, hospital, or medically qualified personnel.

I hereby authorize the release of the results of the examination ta The Company and its representatives. By this authorization, I do hereby release any doctor, hospital, medical center, clinic, medical personnel, etc. and The Company or any of its representatives from any and all liabilities arising from the release or use of the information contained in my physical exam and test results.

MOTOR VEHICLE DRIVER'S Certification of Violations/Annual Review of Driving Record

COMPANY INSTRUCTONS: Each motor carrier shall at least once every 12 months, require each driver it employs to preparE and furnish it with a list or all violations of motor vehicle fraffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391,27. Drivers who have provided information required by Section 383.31 need not repeat that information on this form.

DRIVER REQUIREMENTS: Each driver shall furnish the list as raquired by the motor cartier above. If the driver has not been convicted of, or forfeited bond or collateral) on account of any violation which must be listed, he/she shall so certify (seclion 391.27).

COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS
I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months. No Violations/Annual

If no violations are listed above. I certify that I have not been convicted nor forfeited bond or collateral on account of any viołation (other than those have provided under Part 383) required to be listed durlng the past 12 months.


SHOULD YOU DECIDE TO LEAVE EMPLOYMENT WITHIN SIX MONTHS TO ONE YEAR (1 YEAR) OR ARE DISCHARGED FOR CAUSE DURING THIS PERIOD, YOU AGREE TO REIMBURSE THE COMPANY FOR ALL EXPENSES INCURRED IN ESTABLISHING AND MAINTAINING YOUR ELIGIBILITY, INCLUDING, BUT NOT LIMITED TO, ALL COSTS RELATING TO DRUG TESTING, BACKGROUND CHECKS AND MEDICAL EXAMINATIONS. SUCH EXPENSES MAY BE DEDUCTED FROM ANY SUMS DUE TO YOU AT THE TIME OF YOUR LEAVING EMPLOYMENT.

THESE EXPENSES ARE LISTED, BUT NOT LIMITED TO, THE FOLLOWING:

PRE-EMPLOYMENT DRUG TESTING $75.00

D.0.T. PHYSICAL $50.00

M.V.RACE $15.00

DRIVERS FILES (COMPLETED) $20.00

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TOTAL $160.00

THESE EXPENSES ARE FOR LEASE DRIVERS ONLY:

SPECIAL PERMITS $75.00

UNIFIED CARRIER REGISTRATION $80.00

UNIFIED CARRIER REGISTRATION $20.00

UNIFIED CARRIER REGISTRATION $50.00

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TOTAL $225.00

I, , UNDERSTAND AND AGREE TO ABIDE BY THE ABOVE REQUIREMENTS AND STATEMENTS AS A CONDITION OF EMPLOYMENT.
General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

(As required by Title 49, Subtitle B, Chapter III, Subchapter B, Part 391, Subpart §382.703)

I hereby provide consent to (carrier name) and its' representative Motor Carrier Consultants, Inc. hereafter referred to as the Company, to conduct a limited query of the PMCSA Commercial Driver's License Drug and Alcohol Clearing house (Clearinghouse), prior to my employment and anytime during my employment to determine whether drug or alcohol violation information about me exists in the Clearinghouse.

I understand that if the limited query conducted by the Company indicates that drug or alcohol violatlon information about me exists in the Clearinghouse, the FMCSA will not disclose that information to the Company without first obtaining additional specific consent from me. I aiso understand that in order to provide specific consent, I must register with the Clearinghouse and provide consent within the Clearinghouse.

I further understand that if I refuse to provide consent for the Company to conduct a query of the Clearinghouse, the Company must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations.


ATTN: ALL DRIVER FILE CUSTOMERS RE: CLEARINGHOUSE REQUIREMENTS FOR QUERIES

BEFORE MCCI CAN PROCESS ANY NEW DRIVER APPLICATIONS, THE DRIVER MUST COMPLETE THEIR CLEARINGHOUSE REGISTRATiON. FMcSA REQUIRES ALL PROSPECTIVE EMPLOYERS TO RUN A FULL QUERY INTO EACH DRIVER'S DRUG AND ALCOHOL HISTORY THROUGH THE CLEARINGHOUSE. IN ORDER FOR MCCI TO COMPLETE THIS PROCESS, THE DRIVER MUST COMPLETE THE STEPS BELOW BEFORE YOU FORWARD THEIR DRIVER FILE TO MCO FOR PR0CESSING:

1. Visit https://clearinghouse.fmcsa.dot.gov/register and ciick "Go to login.gov". 2. On the login.gov sign in screen, click "Create an account". 3. Alter creating your login.gov account, continue to the Clearinghouse and complete your Clearinghouse registration. 4. In the Clearinghouse, select your role (Driver) then click Next. 5. Enter your contact and CDL information. 6. Review and accept the Terms and Conditions. 7. AFTER MCCI INITLATES THE QUERY, THE DRIVER WILL RECEIVE AN EMAIL NOTIFICATION TO LOG IN AND COMPLETE THE AUTORIZATION PROCESS. THIS MUST BE DONE PROMPTLY!!

Your registration should be complete

I (prospective driver), attest that i have properly registered for the FMCSA Drug and Alcohol Clearinghouse and understand a full inquiry of my drug and alcohol history will be performed in accordance with DOT regulations. Furthermore, I understand it is my responsibility to complete the authorization process Via Clearinghouse once I receive email notification that the process has been initiated.
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