Executive Chauffeur Job Application Form

List names of non-DOT regulated employers for the past 3 years, and names of all DOT regulated employers for the past 10 years in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references.

PLEASE FILL ADDRESSES OUT COMPLETELY.

Name of Employer: *

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number: *

Date Employed From: *

(Month/Year)

Date Employed To: *

(Month/Year)

Title: *

Duties: *

Reason for Leaving: *

Name and Title of Last Supervisor: *

Were you regulated by the Federal Motor Carrier Safety Administration (FMCSA) during employment? *

Yes No

Were you designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements by 49 CFR part 40? *

Yes No

Would you like to add additional employment history information? *

Yes No

Name of Employer: *

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number: *

Date Employed From: *

(Month/Year)

Date Employed To: *

(Month/Year)

Title: *

Duties: *

Reason for Leaving: *

Name and Title of Last Supervisor: *

Were you regulated by the Federal Motor Carrier Safety Administration (FMCSA) during employment? *

Yes No

Were you designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements by 49 CFR part 40? *

Yes No

Would you like to add additional employment history information? *

Yes No

Name of Employer: *

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number: *

Date Employed From: *

(Month/Year)

Date Employed To: *

(Month/Year)

Title: *

Duties: *

Reason for Leaving: *

Name and Title of Last Supervisor: *

Were you regulated by the Federal Motor Carrier Safety Administration (FMCSA) during employment? *

Yes No

Were you designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements by 49 CFR part 40? *

Yes No

Would you like to add additional employment history information? *

Yes No

Name of Employer: *

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number: *

Date Employed From: *

(Month/Year)

Date Employed To: *

(Month/Year)

Title: *

Duties: *

Reason for Leaving: *

Name and Title of Last Supervisor: *

Were you regulated by the Federal Motor Carrier Safety Administration (FMCSA) during employment? *

Yes No

Were you designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements by 49 CFR part 40? *

Yes No

Would you like to add additional employment history information? *

Yes No

Name of Employer: *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Dates Employed From: *

(Month/Year)

Dates Employed To: *

(Month/Year)

Title: *

Duties: *

Reason for Leaving: *

Name and Title of Last Supervisor: *

Were you regulated by Federal Motor Carrier Safety Administration during employment? *

Yes No

Were you designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40? *

Yes No

In accordance with FMCSA regulation 391.21; paragraph (b)(10) the applicant's previous employers will be contacted, for the purpose of investigating the applicant's safety performance history information as required by paragraphs (d) and (e) of 391.23. The prospective employer must also notify the driver in writing of their due process rights as specified in 391.23(i) regarding information received as a result of these investigations.

***NOTE: An individual Investigation into Safety Performance History form will be sent to each employer listed above.

Name:

First Name Last Name

Phone Number:

Email

example@example.com

Occupation:

Name:

First Name Last Name

Phone Number:

Email

example@example.com

Occupation:

Name:

First Name Last Name

Phone Number:

Email

example@example.com

Occupation:

List your residence history for the past 3 years, starting with your current address. Please include street address and state. Do not leave any blank gaps in time.

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Date Resided From: *

(Month/Year)

Date Resided To: *

(Month/Year)

Would you like to add additional residential history information? *

Yes No

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Date Resided From: *

(Month/Year)

Date Resided To: *

(Month/Year)

Would you like to add additional residential history information? *

Yes No

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Date Resided From: *

(Month/Year)

Date Resided To: *

(Month/Year)

AFFIDAVIT

I recognize that if I am employed, an initial driving history check and criminal background check are required by Kevin Smith Transportation Group. I also acknowledge that additional driving history checks will be required annually. I hereby consent Kevin Smith Transportation Group to conduct an initial driving history check and criminal backgroud check, as well as annual driving checks for the duration of my employment.

I certify that my answers to the foregoing questions are true without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application form or during any interviews may be grounds for my immediate discharge.

I hereby authorize Kevin Smith Transportation Group to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. I also understand that my employment is "at-will" and may be terminated by myself or by the company at any time for any reason or no reason at all, with or without prior notice.

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.

Applicant Signature: *

Clear

Date *

Date

PRE-EMPLOYMENT APPLICATION

PERSONAL INFORMATION

LICENSE AND DRIVING HISTORY:

EMPLOYMENT DESIRED

EDUCATION

CAPABILITY/RELIABILITY

WORK HISTORY

REFERENCES

RESIDENTIAL HISTORY