Star Fleet Application

I am 25 years of age or older

I have a valid driver’s license

I can pass a new DOT physical and obtain 1 year eligibility, Or If given less than 1 year eligibility a physical extended to a full year will need to be obtained prior to expiration of the lesser eligibility

I have No more than 3 moving violations or accidents combined. In the last 3 years

I have No more than 1 preventable accident in the last 3 years

I have NO DUI convictions OR I have only 1 DUI-DWI-OWI-OUI conviction and it is 10 years old or older

Any CARELESS, RECKLESS DRIVING or HABITUAL OFFENDER convictions are 10 years old or older or they have been reviewed with SFT before your lease

Any moving violation suspensions have been reviewed with SFT before your lease

I have listed all prior Felony or Misdemeanor convictions on a separate page and they have been reviewed with SFT before your lease

I have No Drug or Alcohol test failures or refusals

I have No pre-placement drug test failures

I confirm all the above information is true and correct

Contractor's Signature *

Clear

Date *

Date

These Minimum Qualifications have been established for the benefit of safety for the motoring public and our contractors and must be met in order to operate motor vehicles and equipment while under lease to Star Fleet Trucking, Inc

Application for Contractor Star Fleet Trucking, Inc

Date of Application *

Name *

Street *

City *

State *

Zip *

Home Phone

Cell Phone *

If current residency is less than three years please give additional address for the past 3

City, State, Zip

Email *

example@example.com

Date of Birth *

Date

Can you provide proof of age? *

Do you have a legal right to work in the United States of America? *

Have you worked for this company before? *

If so, where?

Start Date

End Date

Position

Reason for leaving

Are you working now?

If not, how long since your last job?

Who referred you?

Is there any reason you might not be able to perform the functions of the job for which you are applying? If yes, please explain

Have you ever tested positive or refused any pre-placement or random drug or alcohol tests?

History

You have the right to review all safety performance history information provided by your previous contracts.All applicants to drive in interstate and intrastate commerce must provide the following information on all contracts or work history during the preceding 10 years. LIST COMPLETE MAILING ADDRESSES, CITY, STATE, ZIP AND PHONE

Name

Start

Date

End

Date

Address

Position Held

City

State

Zip

Salary / Wage

Contact Person

Phone

Reason for Leaving

Were you subject to FMCSR(Federal Motor Carrier Safety Regulations)

No Yes

Was your position designated as a safety sensitive function?

No Yes

Name

Start

Date

End

Date

Address

Position Held

City

State

Zip

Salary / Wage

Contact Person

Phone

Reason for Leaving

Were you subject to FMCSR(Federal Motor Carrier Safety Regulations)

No Yes

Was your position designated as a safety sensitive function?

No Yes

Name

Start

Date

Address

Position Held

City

State

Zip

Salary / Wage

Contact Person

Phone

Reason for Leaving

Were you subject to FMCSR(Federal Motor Carrier Safety Regulations)

Yes No

Was your position designated as a safety sensitive function?

No Yes

Name

Start

Date

End

Date

Address

Position Held

City

State

Zip

Salary / Wage

Contact Person

Phone

Reason for Leaving

Were you subject to FMCSR (Federal Motor Carrier Safety Regulations)

No Yes

Was your position designated as a safety sensitive function?

No Yes

Name

Start

Date

End

Date

Address

Position Held

City

State

Zip

Salary / Wage

Contact Person

Phone

Reason for Leaving

Were you subject to FMCSR(Federal Motor Carrier Safety Regulations)

No Yes

Was your position designated as a safety sensitive function?

No Yes

Name

Start

Date

End

Date

Address

Position Held

City

State

Zip

Salary / Wage

Contact Person

Phone

Reason for Leaving

Were you subject to FMCSR (Federal Motor Carrier Safety Regulations)

No Yes

Was your position designated as a safety sensitive function?

No Yes

Accident Records for the past 3 years. If none, write none.

1

Please enter the following: Date, Nature of Accident, Fatalities, Injuries

2

Please enter the following: Date, Nature of Accident, Fatalities, Injuries

3

Please enter the following: Date, Nature of Accident, Fatalities, Injuries

4

Please enter the following: Date, Nature of Accident, Fatalities, Injuries

Traffic Convictions Moving Violations for the past 3 years. If none write none.

1

Please enter the following: Date, Location, Charge, Fine

2

Please enter the following: Date, Location, Charge, Fine

3

Please enter the following: Date, Location, Charge, Fine

4

Please enter the following: Date, Location, Charge, Fine

Please choose your highest level of education

Driver's License Information

State *

License Number *

Type of License *

Expiration Date *

Date

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes No

Has any license, permit or driving privilege ever been suspended or revoked?

Yes No

If the answer to either A or B is yes, please give details:

Driving Experience. If none, write none.

Straight Truck

Please enter the following: Start and End date, Approx Number of Total Miles

Tractor-Semi Trailer

Please enter the following: Start and End date, Approx Number of Total Miles

Motor coach School Bus

Please enter the following: Start and End date, Approx Number of Total Miles

5th Wheel RV's

Please enter the following: Start and End date, Approx Number of Total Miles

Other

Please enter the following: Start and End date, Approx Number of Total Miles

List all states operated in the last five years.

List special courses or training that you have taken that will help you as a driver

What Safe Driving Awards do you hold and from whom?

**********EMERGENCY CONTACT INFORMATION**********

In the event of an emergency, whom should Star Fleet contact?

Name

First Name Last Name

Telephone Number

Name

First Name Last Name

Telephone Number

TO BE READ AND SIGNED BY THE APPLICANT

This certifies that this application was completed by me and that all entries on it and the information in it are true and complete to the best of my knowledge. I authorize Star Fleet to make such investigations and inquiries of my personal, driving record, work history and other related matters as may be necessary in arriving at a contract decision. In the event of a contract with Star Fleet, I understand that false or misleading information given in my application or interviews may result in discharge.

Signature *

Clear

Date *

Date

YOUR SIGNATURE IS REQUIRED TO OBTAIN YOUR WORK HISTORY FROM YOUR PREVIOUS CONTRACTS.

As an Independent Contractor applicant for Star Fleet Trucking, Inc, I understand FMCSA Regulations require information to be obtained from my previous work history concerning my safety habits, drug & alcohol testing, in accordance with DOT Regulation 49 CFR Part 40 Section 40.25. Work performance and accident reports may also be obtained. I hereby release you from any and all liability, which may result from furnishing this information to Star Fleet Trucking Inc.

Signature *

Clear

Date *

Date

Name *

First Name Last Name

NOTICE OF DUE PROCESS RIGHTS AND AUTHORIZATION

Name *

First Name Last Name

Date *

Date

TO BE READ AND SIGNED BY POTENTIAL CONTRACTOR

I authorize you to make such investigations and inquires of my personal, work history, financial or medical history and other related matters as may be necessary in arriving at a contract decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of a contract has been extended.) I hereby release companies/person(s), schools, health care providers from all liability in aiding to inquiries and releasing information in connection with my application for contract.

In the event of offered contract, I understand that false or misleading information given in y application or interview(s) may result in disharge.

I understand information I provide regarding current or previous work history may be used and companies/persons 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 previous work history;
Have errors in the information corrected by the previous companies/person(s) and for those previous companies/persons to re-send the corrected information to Star Fleet Trucking Inc; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous companies/person(s) and I disagree on the accuracy of the information.

Signature *

Clear

Date *

Date

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALLACCOUNT HOLDERS

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Star Fleet Trucking, Inc (“Prospective Employer”) Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to ta ke the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and w here those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Star Fleet Trucking, Inc (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP)system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.

*I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.*

Date *

Date

Name *

First Name Last Name

Signature *

Clear

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49
C.F.R. 383.5.

LAST UPDATED 12/22/2015

Employee means any operator of a commercial motor vehicle, including full time, regularly employed drivers; casual, intermittent or occasional drivers; leased drivers and independent, owner-operator contractors (while in the course of
operating a commercial motor vehicle) who are either directly employed by or under lease to an employer.

This definition is found in 49 C.F.R. 383.5.

Equipment Information

Year

Make

Model

Empty Weight

Manufacturers GVWR

Axles

Owner's Name

First Name Last Name

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration
(FMCSA) Drug and Alcohol Clearinghouse

I, First Name* Last Name* , hereby provide consent to Star Fleet Trucking Inc., to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol
Clearinghouse, to determine whether drug or alcohol violation information about me exists in the Clearinghouse. Said consent shall apply to multiple limited queries and only will be effective during the preliminary investigation of my application for contract to Star Fleet Trucking, Inc. I further agree that I will execute additional continuing consent for multiple limited queries if I enter into a contract with Star Fleet Trucking, Inc.
I understand that if a limited query conducted by Star Fleet Trucking, Inc. indicates that a drug or alcohol violation information exists in the Clearinghouse, FMCSA will not disclose that information to Star Fleet Trucking Inc. without obtaining additional specific consent from me. I further understand that if I refuse to provide consent for Star Fleet Trucking Inc. to conduct a limited query of the Clearinghouse, Star Fleet Trucking Inc. must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA drug and alcohol program regulations.

Signature *

Clear

Date *

Date

Application for Contractor Star Fleet Trucking, Inc

Application for Contractor Star Fleet Trucking, Inc

Place of Business 1

Place of Business 2

Place of Business 3

Place of Business 4

Place of Business 5

Place of Business 6