Test Step 1 of 11 9% Driver Application for Employment (Please use capital letters when completing)In compliance with federal and provincial employment opportunities laws, qualified applicants are considered for all positions without regard to race, colour, region, sex, national origin, age, marital status or non-job related disability.Positions Applied for Name First Middle Last PhoneCell PhoneList addresses for the past 5 years beginning with most recent:Address City State ZipHow long Address City State ZipHow long Address City State ZipHow long Address City State ZipHow long Address City State ZipHow long Do you have legal right to work in the United States? Yes No Social Security Number:NumberNumberNumberDate of Birth MM slash DD slash YYYY (Required for commercial drivers)Can you proof of age? Yes No License Information: Section 382.21 FMCSR states "No person who operates a commercial motor vehicle shall 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 NoType Expiry Date MM slash DD slash YYYY Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No Please ExplainHas any license, permit or privilege ever been suspended or revoked? Yes No Please ExplainHave you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes No Please ExplainIs there any reason you might be unable to perform the functions of the job you have applied for? Yes No Please ExplainEducationChoose the highest grade completed 1 2 3 4 5 6 7 8 High School 1 2 3 4 College 1 2 3 4 Last School attendedName NameCIty CIty Employment History All driver applicants to to drive in interstate commerce must provide the following information on all employers during the preceding 5 years. Please use another sheet if required.Company Name Contact Name Address City State Zip Phone NumberFrom To Position Held Wages/Salary Reason for leaving Company Name Contact Name Address City State Zip Name First Last Phone NumberFrom To Position Held Wages/Salary Reason for leaving Company Name Conatact Name Address City State Zip Phone NumberFrom To Position Held Wages/Salary Reason for leaving Company Name Conatct Name Address City State Zip Phone NumberFrom To Position Held Wages/Salary Reason for leaving Driving Experience:Class of equipment (Straight Truck)Type of Equipment (Van, Flat, Tank, etc.) From (MM/YY) To (MM/YY) Approx Total Miles Class of equipment (Tractor and Semi-Trailer)Type of Equipment (Van, Flat, Tank, etc.) From (MM/YY) To (MM/YY) Approx Total Miles Class of equipment (Tractor - 2 Trailers)Type of Equipment (Van, Flat, Tank, etc.) From (MM/YY) To (MM/YY) Approx Total Miles Class of equipment (Other)Type of Equipment (Van, Flat, Tank, etc.) From (MM/YY) To (MM/YY) Approx Total Miles List Province/States operate in for last 5 yearsList special courses or training taken that will help you as a driver:Which safe driving award do you hold and from whom? Accident records for the last 3 yearsDate Nature of Accident Injuries/Fatalities Charges Date Date Date Date Date Date Date Date Motor Vehicle Driving OffencesDate Location Charge Penalty Alcohol & Control Substance Statement1. Within the last 2 years, have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administrated by an Employer to which you applied for, but did not obtain, safety-sensitive transportation work? Yes No 2. Within the last 2 years, have you ever tested positive, or refused to test, on any type of drug or alcohol test administrated by an employer for which ypu performed safety-sensitive transportation work? Yes No 3. Can you provide and/or obtain proof that you have successfully completed the DOT return-to-duty requirements? Yes No Applicant's SignatureDate MM slash DD slash YYYY Witnessed By Date MM slash DD slash YYYY TO BE READ AND SIGNED BY APPLICANT I certify that I have read and understand all of this employment application. It is agreed and understood that the employer or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and other persons named herein from all liability for any damages on account of his furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks that are pertinent to the job. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, personal reputation, personal characteristics and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal. If hired, I agree to abide by all the rules and policies of the employer. This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of my knowledge. Applicant's SignatureDate MM slash DD slash YYYY Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Suggested Format: “Release of Information Form -- 49 CFR Part 40 Drug and Alcohol Testing”Section I. To be completed by the new employer, signed by the employee, and transmitted to the previous employer:Employee Printed or Typed Name: Employee SS or ID Number: I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer, listed in Section I-B, to the employer listed in Section I-A. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released in Section II-A by my previous employer, is limited to the following DOT-regulated testing items: 1. Alcohol tests with a result of 0.04 or higher; 2. Verified positive drug tests; 3. Refusals to be tested; 4. Other violations of DOT agency drug and alcohol testing regulations; 5. Information obtained from previous employers of a drug and alcohol rule violation; 6. Documentation, if any, of completion of the return-to-duty process following a rule violation. Employee Signature:Date MM slash DD slash YYYY I-A.New Employer Name: Address: Phone #:Fax #: Designated Employer Representative: I-B.Previous Employer Name: Address: Phone #:Designated Employer Representative (if known): Section II. To be completed by the previous employer and transmitted by mail or fax to the new employer: II-A. In the two years prior to the date of the employee’s signature (in Section I), for DOT-regulated testing ~ 1. Did the employee have alcohol tests with a result of 0.04 or higher? Yes No 2. Did the employee have verified positive drug tests? Yes No 3. Did the employee refuse to be tested? Yes No 4. Did the employee have other violations of DOT agency drug and alcohol testing regulations? Yes No 5. Did a previous employer report a drug and alcohol rule violation to you? Yes No 5. Did a previous employer report a drug and alcohol rule violation to you? Yes No 6. Did the employee complete the return-to-duty process? Yes No NOTE: If you answered “yes” to item 5, you must provide the previous employer’s report. If you answered “yes” to item 6, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record). II-B.Name of person providing information in Section II-A: Title: Phone #:Date: MM slash DD slash YYYY SAFETY PERFORMANCE HISTORY RECORDS REQUEST PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEEI, (Print Name) First Middle Last Social Security Number Hereby authorize: Date of Birth MM slash DD slash YYYY Previous Employer: Email Street: TelephoneCity, State, Zip: Fax No.: To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from MM slash DD slash YYYY (employment application date) To Prospective Employer: Attention: Telephone:Street: City, State, Zip: In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter. Prospective employer’s fax number: Prospective employer’s email address: Applicant’s SignatureDate MM slash DD slash YYYY This information is being requested in compliance with §40.25(g) and 391.23. PART 2: TO BE COMPLETED BY PREVIOUS EMPLOYER ACCIDENT HISTORY The applicant named above was employed by us. Yes No Employed as from to 1. Did he/she drive motor vehicle for you? Yes No What type? Straight Truck Tractor-Semitrailer Bus Cargo Tank Doubles/Triples Other (Specify) Specify 2. Reason for leaving your employ: Discharged Resignation Lay Off Military Duty If there is no safety performance history to report, check here , sign below and return. ACCIDENTS: Complete the following for any accidents included on your accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or check here if there is no accident register data for this driver. 1. Date MM slash DD slash YYYY 2. Date MM slash DD slash YYYY 3. Date MM slash DD slash YYYY 1. Location 2. Location 3. Location 1. Injuries 2. Injuries 3. Injuries 1. Fatalities 2. Fatalities 3. Fatalities 1. Hazmat Spill 2. Hazmat Spill 3. Hazmat Spill Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies:Any other remarks:Signature:Title: Date MM slash DD slash YYYY PREVIOUS EMPLOYER – 2 PART 3 PART 3: TO BE COMPLETED BY PREVIOUS EMPLOYERIf driver was not subject to Department of Transportation testing requirements while employed by this employer, please check here , fill in the dates of employment from to complete bottom of Part 3, sign, and return.Driver was subject to Department of Transportation testing requirements from to 1. Has this person had an alcohol test with the result of 0.04 or higher alcohol concentration? Yes No 2. Has this person tested positive or adulterated or substituted a test specimen for controlled substances? Yes No 3. Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test? Yes No 4. Has this person committed other violations of Subpart B of Part 382, or Part 40? Yes No 5. If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-prescribed rehabilitation program in your employ, including return-to-duty and follow-up tests? If yes, please send documentation back with this form. Yes No 5. If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-prescribed rehabilitation program in your employ, including return-to-duty and follow-up tests? If yes, please send documentation back with this form. Yes No 6. For a driver who successfully completed a SAP’s rehabilitation referral and remained in your employ, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested? Yes No In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previous employers in the previous 3 years prior to the application date shown on part 2. Name: Company: Street: City, State, Zip: Telephone:Part 3 Completed by (Signature):Date MM slash DD slash YYYY PART 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYERThis form was- Faxed to previous employer Mailed Emailed Other Specify By Date MM slash DD slash YYYY PART 4b: TO BE COMPLETED BY PROSPECTIVE EMPLOYERComplete below when information is obtained.Information received from: Recorded by: Method: Fax Mail Email Telephone Other Date MM slash DD slash YYYY Specify INSTRUCTIONS TO COMPLETE THE SAFETY PERFORMANCE HISTORY RECORDS REQUEST PAGE 1 PART 1: Prospective Employee Complete the information required in this section Sign and date Submit to the Prospective Employer PAGE 2 PART 4a: Prospective Employer Complete the information Send to Previous Employer PAGE 1 PART 2: Previous Employer Complete the information required in this section Sign and date Turn form over to complete SIDE 2 SECTION 3 PAGE 2 PART 3: Previous Employer Complete the information required in this section Sign and date Return to Prospective Employer PAGE 2 PART 4b: Prospective Employer Record receipt of the information Retain the form RECORDS REQUEST FORDRIVER/APPLICANT SAFETY PERFORMANCE HISTORYThis request is made by the driver/applicant in compliance with the Department of Transportation regulations. 391.23(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safety-performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.PART 1: COMPLETED BY THE DRIVER/APPLICANT TO: Prospective Employer: Street/P.O. Box: City, State, Zip: Telephone # From: Driver/Applicant: Social Security/I.D. # Street: City, State, Zip: Telephone # I am submitting this written request to obtain copies of my Department of Transportation Safety Performance History for the preceding three years. I understand, for records requested from a prospective employer, that I must arrange to pick up or receive the requested records within thirty (30) days of the records being made available or I have waived my request to review the records. This information should be: Sent to me at the above address. I will arrange to pick up. Driver/Applicant Signature:Date MM slash DD slash YYYY PART 2: COMPLETED BY THE PROSPECTIVE EMPLOYERThe information must be provided to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information form the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safety performance history information. Information supplied to: Name: Street: City, State, Zip: Comments: By: Signature/person providing informationTelephone #Release Date: MM slash DD slash YYYY Join our Team Current Job Openings Start driving with a great company. Company Services Contact Quick Contact 2550 Union Hills Drive Suite 350, Phoenix, AZ 85027 (623)248-6932 firstname.lastname@example.org Linkedin © 2021 DSP Trucking Inc. Website designed by Agile Website Solutions.