Application / 800 RoadAid

FULL NAME

SOCIAL SECURITY NUMBER

DATE OF BIRTH

PICK-UP TIME

PHONE NUMBER

CURRENT ADDRESS

PREVIOUS 3 YEARS

IN CASE OF EMERGENCY, NOTIFY

PHONE NUMBER

POSITION APPLYING FOR

PAY RATE EXPECTED

Have you worked for this company before?: Yes No If yes, from

To

Are you employed?: Yes No When will you be available?

Are you prevented from lawful employment in this country because of immigration status?: Yes No

Have you ever been convicted of a felony, misdemeanor, or criminal violation?: Yes No

VALID DRIVER’S LICENSE NUMBER

STATE

EXPIRATION

LISCENSE TYPE (I.E. CDL CLASS A)

CDL ENDORSEMENTS

Has your license, permit, or privilege to operate a motor vehicle ever been denied, revoked, or suspended?: Yes No

Have you ever been disqualified under §383 or §391 of the federal motor carrier safety regulations?: Yes No

I CERTIFY THAT I DO NOT HAVE MORE THAN ONE DRIVER’S LICENSE

LAST GRADE COMPLETED

COLLEGE

OTHER TRAINING

Do you have full knowledge of the federal motor carrier safety regulations?: Yes No

TYPE OF EQUIPMENT

NUMBER OF YEARS

STATES YOU HAVE DRIVEN IN

DATE

NATURE OF ACCIDENT

FATALITIES

INJURIES

TYPE OF VEHICLE

STATE

DATE

CHARGE

PENALTY

TYPE OF VEHICLE

Non CDL-Driver applicants must provide 3 years employment history. CDL driver applicants must provide 10 years. We are required under §391.23 to investigate your safety performance history of all Federal Motor Carrier Safety Administration regulated employers that you worked for in the preceding 3 years. We are required to investigate your participation in a U.S. DOT mandated drug and alcohol testing program, whether you violated any prohibitions under §382 subpart B, and whether you failed to undertake or complete rehabilitation as required under §382.605 or subpart O §40 of all U.S. DOT regulated employers that you worked for in the preceding 3 years. You must give written consent for these investigations in order to to be considered for employment as a driver. You have due process rights regarding the information received from these investigations under §391.23(i). ALL INFORMATION OBTAINED FROM PREVIOUS EMPLOYERS WILL BE KEPT CONFIDENTIAL.

NAME OF EMPLOYER

PHONE NUMBER

ADDRESS

SUPERVISOR’S NAME

POSITION

EMPLOYED FROM

TO

REASON FOR LEAVING

Did you perform “Safety sensitive functions” while employed?: Yes No

Did you operate a CDL Vehicle?: Yes No

Were you subject to the Federal Motor Carrier Safety Regulations while employed?: Yes No

Applicant: If employer has not explained or given a job description, make sure one is given to you and that you fully understand what is expected of you prior to answering the following two questions.

Can you perform the functions described in the job Description?: Yes No

I agree and understand that any misrepresentations or omissions of information or facts given on this form shall be considered and act of falsification.

I agree and understand that the carrier and its agents may investigate and and all information given on this form to determine its validity. I understand that all employment information from previous employers will be used by the carrier only as part of deciding whether to hire me.

I understand that under U.S. DOT regulation §391.23(i), I cannot bring and action or proceeding for defamation, invasion of privacy, or interference with a contract against this carrier or any previous employer based on furnishing or using employment history information.

I agree to furnish such additional information and complete such examinations as may be required to complete my driver qualification and employment files.

If hired, I agree to abide by all the rules and policies of this carrier.

DATE

APPLICANT SIGNATURE

APPLICATION FOR EMPLOYMENT

Specialized transport services throughout the 48 Contiguous United States

Our Affiliations

APPLICATION FOR EMPLOYMENT

Specialized transport services throughout the 48 Contiguous United States

Our Affiliations

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