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Driver Application Form
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TO BE READ AND SIGNED BY APPLICANT
I authorize you to make such investigations and inquiries of my personal, employment, financial or 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 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 that false or misleading information given in my application or interview(s) may result in discharge. 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 may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:
Review information provided by current/previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send 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."
By signing in the space below you have read, understand and agree to the above terms and conditions.
Write your signature
*
Date of Application
*
MM slash DD slash YYYY
Name
*
First
Last
Indicate the position you are applying for
*
Social Security Number
*
Phone Number
*
Date of Birth
*
MM slash DD slash YYYY
Available start date
*
MM slash DD slash YYYY
ADDRESS
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Number of Years at Present Address
*
1
2
3
4+
PAST 3 YEAR RESIDENCY
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Number of Years at Past 3 Year Residency
*
Employment History (Use Additional Employment History Information form if necessary)
All applicants wishing to drive in interstate commence must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle sever year prior to the initial three years
(total of ten year employment record)
.
You are required to list the complete mailing address: street number and name, city, sate and zip code.
CURRENT OR LAST EMPLOYER
*
Phone Number
*
Street Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Position Held
*
From
*
MM slash DD slash YYYY
To
*
MM slash DD slash YYYY
Reasons for Leaving
*
Were you subject to the FMCSRs** while employed
*
Yes
No
Was your job designated as a safe-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
*
Yes
No
ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason:
Add second employer?
Yes
No
SECOND LAST EMPLOYER
*
Phone Number
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Position Held
*
From
*
MM slash DD slash YYYY
To
*
MM slash DD slash YYYY
Reasons for Leaving
*
Were you subject to the FMCSRs** while employed
*
Yes
No
Was your job designated as a safe-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
*
Yes
No
ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason:
Add third employer?
Yes
No
THIRD LAST EMPLOYER
*
Phone Number
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Position Held
*
From
*
MM slash DD slash YYYY
To
*
MM slash DD slash YYYY
Reasons for Leaving
*
Were you subject to the FMCSRs** while employed
*
Yes
No
Was your job designated as a safe-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
*
Yes
No
ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason:
Add additional employers?
Yes
No
Please enter the name of the company, term of employment (in months and or years) along with company address and phone number, up to ten years previous experience, in this field below.
* Any gaps in employment and/or unemployment must be explained.
** 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 a quantity requiring placarding.
EXPERIENCE AND QUALIFICATION
Driving Experience
Do you have driving experience within the last 3 years
*
Yes
No
Straight Truck
Yes
No
Straight Truck Options (check all that apply)
Van
Reefer
Tank
Flat
Other
Straight Truck - Other
Straight Truck - Date From
MM slash DD slash YYYY
Straight Truck - Date To
MM slash DD slash YYYY
Approximate Number of Miles
*
Tractor & Semi-Trailer
Yes
No
Tractor & Semi-Trailer Options (check all that apply)
Van
Reefer
Tank
Flat
Other
Tractor & Semi-Trailer - Other
Tractor & Semi-Trailer - Date From
MM slash DD slash YYYY
Tractor & Semi-Trailer - Date To
MM slash DD slash YYYY
Approximate Number of Miles
*
Two Trailers - Tractor
Yes
No
Two Trailers - Tractor Options (check all that apply)
Van
Reefer
Tank
Flat
Other
Two Trailers - Tractor - Other
Two Trailers - Tractor - Date From
MM slash DD slash YYYY
Two Trailers - Tractor - Date To
MM slash DD slash YYYY
Approximate Number of Miles
*
Three Trailers - Tractor
Yes
No
Three Trailers - Tractor Options (check all that apply)
Van
Reefer
Tank
Flat
Other
Three Trailers - Tractor - Other
Three Trailers - Tractor - Date From
MM slash DD slash YYYY
Three Trailers - Tractor - Date To
MM slash DD slash YYYY
Approximate Number of Miles
*
Motocoach-School Bus (Greater than 8 passenger)
Yes
No
Motocoach-School Bus 8+ Options (check all that apply)
Van
Reefer
Tank
Flat
Other
Motocoach-School Bus 8+ - Other
Motocoach-School Bus 8+ - Date From
MM slash DD slash YYYY
Motocoach-School Bus 8+ - Date To
MM slash DD slash YYYY
Approximate Number of Miles
*
Motocoach-School Bus (Greater than 15 passenger)
Yes
No
Motocoach-School Bus 15+ Options (check all that apply)
Van
Reefer
Tank
Flat
Other
Motocoach-School Bus 15+ - Other
Motocoach-School Bus 15+ - Date From
MM slash DD slash YYYY
Motocoach-School Bus 15+ - Date To
MM slash DD slash YYYY
Approximate Number of Miles
*
Equ Class - Other
Yes
No
Equ Class Other
Other Equ Class Options (check all that apply)
Van
Reefer
Tank
Flat
Other
Other Equ Class - Other
Other Equ Class - Date From
MM slash DD slash YYYY
Other Equ Class - Date To
MM slash DD slash YYYY
Approximate Number of Miles
*
EXPERIENCE AND QUALIFICATION (continued)
Accident History
Do You Have any Accidents Within the Last 3 Years
*
Yes
No
Date
*
MM slash DD slash YYYY
Nature of Accident (head-on, rear-end, upset, etc.)
*
Number of Fatalities
*
Number of Injuries
*
Hazardous Materials Spill
*
Yes
No
Add a Second Accident?
Yes
No
Date
*
MM slash DD slash YYYY
Nature of Accident (head-on, rear-end, upset, etc.)
*
Number of Fatalities
*
Number of Injuries
*
Hazardous Materials Spill
*
Yes
No
Add a Third Accident?
Yes
No
Date
*
MM slash DD slash YYYY
Nature of Accident (head-on, rear-end, upset, etc.)
*
Number of Fatalities
*
Number of Injuries
*
Hazardous Materials Spill
*
Yes
No
Traffic Convictions and Forfeitures
Do You Have any Traffic Convictions and/or Forfeitures Within the Last 3 Years
*
Yes
No
Date Convicted
*
MM slash DD slash YYYY
Violation (other than parking)
*
State of Violation
*
Penalty (forfeited bond, collateral and/or points)
*
Add Another Conviction/Forfeiture?
Yes
No
Date Convicted - 2
*
MM slash DD slash YYYY
Violation (other than parking) - 2
*
State of Violation - 2
*
Penalty (forfeited bond, collateral and/or points) - 2
*
License Information
Section 383.21 FMCSr states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.
State
*
License Number
*
License Class Type
*
Expiration Date
*
MM slash DD slash YYYY
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
*
Yes
No
Please Give Details
B. Has any license, permit, or privilege ever been suspended or revoked?
*
Yes
No
Please Give Details
Applicant Certification
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.
Write your signature
*
Date
*
MM slash DD slash YYYY
CONSUMER DISCLOSURE AND AUTHORIZATION FORM
Disclosure Regarding Background Investigation
Sallee Horse Vans Inc (the "Company") may request, for lawful employment purposes, background information about you from a consumer reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable). This background information may be obtained in the form of consumer reports and/or investigative consumer reports (commonly known as "background reports"). These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by the Company, throughout your employment or your contract period.
HireRight, Inc., or another consumer reporting agency, will prepare or assemble the background reports for the Company. HireRight, Inc. is located and can be contacted by mail at 5151 California, Irvine, CA 92617, and HireRight can be contacted by phone at (800) 400-2761.
The types of information that may be obtained include, but are not limited to: social security number verifications; address history; credit reports and history; criminal records and history; public court records; driving records; accident history; worker's compensation claims; bankruptcy filings; educational history verifications (e.g., dates of attendance, degrees obtained); employment history verifications (e.g., dates of employment, salary information, reasons for termination, etc.); personal and professional references checks; professional licensing and certification checks; drug/alcohol testing results, and drug/alcohol history in violation of law and/or company policy; and other information bearing on your character, general reputation, personal characteristics, mode of living and credit standing.
This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses; educational institutions; former employers; personal interviews with sources such as neighbors, friends and associates; and other information sources. If the Company should obtain information bearing on your credit worthiness, credit standing or credit capacity for reasons other than as required by law, then the Company will use such credit information to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being evaluated.
You may request more information about the nature and scope of any investigative consumer reports by contacting the Company. A summary of your rights under the Fair Credit Reporting Act is also being provided to you.
Additional State Law Notices
If you are a California, Maine, Massachusetts, New York or Washington State applicant, employee or contractor, please also note:
CALIFORNIA:
Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by HireRight during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at HireRight's offices in person, during normal business hours and on reasonable notice, or by mail. You may also receive a summary of the file by telephone, upon submitting proper identification. HireRight has trained personnel available to explain your file to you, including any coded information. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification.
MAINE:
You have the right, upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any such reports.
MASSACHUSETTS:
If we request an investigative consumer report, you have the right, upon written request, to a copy of the report.
NEW YORK:
You have the right, upon request, to be informed of whether or not a consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency. Please click h= for additional information about New York law, as applicable.
WASHINGTON STATE:
If the Company requests an investigative consumer report, you have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation requested by the Company. You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Authorization of Background Investigation
I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as HireRight, Inc., and to the release of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may obtain background reports, throughout my employment or contract period.
I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services.
I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency.
By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any background reports that may be requested by or on behalf of the Company.
California, Minnesota or Oklahoma applicants only:
You will be provided with a free copy of any consumer reports or investigative consumer reports obtained on you if you check the box below.
I wish to receive a free copy of the report.
Yes
No
Applicant Name
*
First
Last
Write your signature
*
Date
*
MM slash DD slash YYYY
Write your signature
*
Date of Application
*
MM slash DD slash YYYY
Please take a moment to verify all of your information is correct, once you click submit you can not go back and make changes.
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