DRIVER'S APPLICATION FOR EMPLOYMENT

Transcription

1 DRVER'S APPLCATON FOR EMPLOYMENT GORDON MLK TRANSPORT 9060 Bollman Rd. Sugarcreek, Ohio (answer all questions - please print) This company is an equal opportunity employer in compliance with all Federal and State equal employment oppottunity laws. Consideration of qualified applicants for any position is made without regard to the applicant's sex, race, color, national origin, marital status, age, religion, or non-job related disability. *Date: *Phone: *Name: *: ''Date c!f'birth: Social Security Number: *.Previous : ~-: Go back 3 years) (Street) () (State & Zip) (Street) Driving Qualifications and Experience () (State & Zip) LCENSE HELD: State: -- License Number: ' Type: Expiration Date: A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? B. Has any license, permit, or privilege ever been suspended or revoked? F THE ANSWER TO ETHER S YES, EXPLAN ON BACK OF THS SHEET. Yes Yes No No EQUPMENT EXPERENCE: Equipment CJ ass Equipment Type For How Long? (Van, Flat, Tank, Reefer) Tractor & Sen 1i-Trailer Tractor w/tw o Trailers ~traight Total Miles (appx.) *Jn what States have you operated - past 3 years? :_-' ~

2 Accident Record for past 3 years or more DA TE OF ACCDENT NATURE OF ACCDENT FATALTES NJURES (ATACH ADDT 0NAL SHEET F NEEDED) ' Traffic Convictions and Forfeitures for the past 3 years (other than parking violations) LOCATON CHARGE PENALTY, > (ATACH ADDTONALSHhEl FNEEDED) EMPLOYMENT HSTORY: All applicants must provide the following information on all employers during the preceding 3 years. nformation must be complete and correct. Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with most recent. Add another sheet if necessary.) Name From MO/YR To MO/YR Were you subject to the FMCSRs while employed? [ ] Yes [ ] No Was your job designated as a safety-sensitive function many DOT-regulated mode subject to the Drug and Alcohol testing requirements of 49 CFR PART 40? [ ] Yes [ ] No Name From MO/YR ToMO/YR.. Were you subject to the FMCSRs while employed? [ ] Ye.<i ( ] No Was your Job designated as a safety-sensitive function many DOT-regulated mode subject to the Drug and Alcohol testing requirements of 49 CFR PART 40? [ J Yes [ ] No Name From MO/YR ToMONR Were you subject to the FMCSRs while employed? [ ] Yes [ ) No Was your JOb designated as a safety-sensitive function many DO'f.. regulated mode subject to the Drug and Alcohol testing requirements <Jf 49 CFR PART 40? [ ] Yes [ ] No

3 Name From MO/YR To MO/YR Were you subject to the ' MCSRs while employed? [ ] Yes [ ] No Was your.1ob designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol testing requirements of 49 CFR PART 40? [ ] Yes [ ] No Name From MO/YR ToMO/YR.. Were you subject to the FMCSRs while employed? [ ] Yes [ ] No Was your JOb designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol testing requirements of 49 CPR PART 40? [ ] Yes [ ] No EDUCATON: CRCLE HGHEST GRADE COMPLETED: HGH SCHOOL: COLLEGE: Last School Attended -~-- (N'iune) () ~ ~..-- Q BE READ AND SGNED BY ~f PLCANT 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. 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 hb.tory will be made only if and after a conditional ofter of employment has been extended.) hereby release employers, schools. health care providers and other persons of history all liability in responding to inquiries and releasing information in connection with my application. n the event of employment, l understand that false or misleading information given in my application or interview(s), may result in discharge. understand, also, that lam required to abide by all rules and regulations of the Company. Date: x ---- Applicant's Signature ~ ADDENDUM TO DRVER APPLCATON Pursuant to changes to Part 40 of the Federal Motor Carrier Safety Regulations, this Addendum to the Drivers Application for employment must be completed by each applicant. Have you, the applicant, tested positive or refuse to be tested on any Pre-Employment drug or alcohol test administen.>d by an employer to which you applied for, but did not obtain, safety-sensitive transpnrtaticm work covered by DOT agency drug and alcohol testing rules during the past two years? [ ] YES [ ] NO f your answer to the above question is yes, please list the motor carrier(s) you applied to below: Name of Motor Carrier: Phone#: n addition, if the answer to the above question is yes, please list the name and phone number of the Substance Abuse Professional who managed your evaluation: Name of SAP: Phone#: x Signature of Applicant (Date)

4 GENERAL RELEASE n connection with my preliminary application with GORDON MLK TRANSPORT, understand that a report, which may contain public record information, is being requested from various sources. This report may include the following types of information: -----names and dates of previous employment -----reasons for termination -----alcohol tests with a concentration result of 0.04 or greater -----controlled substance testing -----refusals of applicant to test ---- work experience, accidents, etc. further understand that such report may contain information concerning my driving record from state and other agencies which maintain such records as well as information concerning previous driving requests made by others from such agencies; state provided driving record and claims involving me in the files of insurance companies. hereby authorize, without reservation, any part or agency contacted by GORDON MLK TRANSPORT or its authorized representatives to furnish the above mentioned information without fear or reprisal, accordingly those furnishing such information are hereby released from any and all liability which result from furnishing such information. have the right to make a request, upon proper identification, to request the nature and substance of all information from GORDON MLK TRANSPORT at the time of my request and the sources of information. hereby authorize to GORDON MLK TRANSPORT obtaining the above information. have been informed. by GORDON MLK TRANSPORT, that have the right to review information provided by my previous employers, that have 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 GORDON MD..K TRANSPORT. That have also been informed that have the right to have a. rebuttal statement attached to the alleged errotteous information, if the previous employer and cannot agree on the accuracy of the nformation. (Applicant's Signature) Date: Applicant Name: SSN: Prospective Employer: GORDON MLK TRANSPORT 1083 Ragersville Rd. Sugarcreek, Ohio 44681

5 REQUEST FOR NFORMATON FROM PREVOUS hereby authorize you to release the following information to: GORDON MLK TRANSPORT (Prospective Employer) for the purpose of investigation as required by Section of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from such information. Date: Applicant's Signature: X NFORMATON REQUESTED FROM: Previous Employer's Name: Contact:. :. State:.Zip: Phone: To whom it may concern: The person named below has, while seeking employment with this company as a Driver, stated that they held a position with your company as a from to _ Your time in answering the questions in the form below is greatly appreciated. Be assured that you provide this information in confidence, to assist in this company's hiring process. Thank you for your assistance. (Signature and Title of Company Representative) Name of Applicant: SSN: 1. Employed from to as Did he/she drive motor vehicle for you? Straight Truck? Tractor-Semitrailer? Bus'i> Other (specify) Was he/ she a safe and efficient driver? 4. Reason for leaving your employ: Discharge Resignation_Layoff 5. Was general conduct satisfactory? Person Contacted or supplying nformation; Date:

6 PREVOUS S DRUG & ALCOHOL TESTNG CONFRMATON (Conforms with 49 CFR Part 40) n accordance with Part of the Federal Motor Carrier Safety Regulations, an employer shall obtain, from a driver's previous employer, information on a driver's alcohol test with a concentration result of 0.04 or greater, positive controlled substance test results, and refusals to be tested within the preceding two years. The above information must be obtained and reviewed by the prospective employer no later than 14 calendar days after the first time a driver performs safety sensitive functions for an employer. The previous employer must provide this information as required by law and contained in Part DRVER/ APPLCANT AUTHORZATON TO RELEASE RESULTS, (Driver/ Applicant Name) (Social Security Number) in connection with my employment application for employment at; GORDON MLK TRANSPORT (Prospective Employer) hereby authorize responsible persons involved in the drug and alcohol testing program at: Previous Employer: :, State, Zip: Phone No.: to release to: GORDON MLK TRANSPORT all requested information. (Prospective Employer) x (Driver/ Applicant Signature) (Date) CONFRMATON n accordance with the above listed driver's authorization to release results, the following information is presented: Name of Previous Employer: Previous Employer Representative: Date & Time Contacted:. Driver has participated in Drug and Alcohol Program since: *Has driver, during the two years previous to_/, tested positive for drugs: DYes DNo *Has driver, during the two years previous to_/, tested greater than.04 for alcohol:!!yes DNo *Has driver refused to be drug or alcohol tested: DYes ONo PLEASE NOTE: F DRUG TEST WAS POSTVE OR F ALCOHOL TEST WAS 0.04 OR GREATER, OR F DRVER REFUSED A DRUG OR ALCOHOL TEST, A SUBSTANCE ABUSE PROFESSONAL CONFRMATON REPORT WLL BE PROVDED AND MUST BE COMPLETED. Name of Person taking report: Date Report Rec'd:

7 Brase Enterprises nc. DBA Gordon Milk MOTOR VEfilCLE RECORD REQUEST The position which you are applying for may involve 1he driving of company vehicles. As a condition of employment with Drasc Enterprises nc. DBA Gordon Milk, your driving record will be investigated by our insurance agen~ The Church Agency, nc. or its assigns, for the purpose of obtaining coverage for you. Driver's License Number ~~~~~~~~~~~- State Social Security Number. CHECK 11E APPROPRATE BOX FOR EACH QUESTON: YES NO Have you ever been denied a driver's license or bad one suspended or revoked? Have you had any moving traffic violations in the past 3 years Have you had any auto accidents in the past 3 years D D F THE ANSWER TO ANY QUESTON WAS "YES". EXPLAN (give dates of violations and for accidents) hereby grant pennission for Drasc Ent lne. DBA Gordon Milk to secure a Motor Vehicle Report on me. understand that in obtaining such a report, a consumer reporting agency may be used. also affirm that the statements made above are stated truthfully and without reservation. Signed this day of,, 20_. Driver's Signature