JTS transport - Online Driver Application

DRIVER APPLICATION

APLICACION DE CHOFER
Date *

Month Day Year
Date
Name *

First Name Last Name
Per FMCSA's 391.23 (Investigation and Inquiries), subpart (J): (Driver) I understand that I have the right to: Review information provided by current/previous employers: Have errors in the information corrected by previous employers and or those previous employers to re-send the corrected information to the prospective employer; and have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and cannot agree on the accuracy of the information.

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard the race, color, religion, sex, national origin, age, marital status, or the presence of a non-job related medical condition or handicap. / En cumplimiento conlas leyhes federales y estatales de igualdad de empleo, aplicates calificados son considerados para empleo, aplicantes calificados son considerados para empleo sin distincion de raza, color, religion, sexo, origen, edad, estado civil, o la presencia de salud fisica no relacionada con ese empleo.
Position (s) applied for / Posicion a que aplica: *
Referred By / Referido por
Social Security / Seguro Social *
Date of Birth / Fecha de nacimiento *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
CDL/CDL: *
CDL Expiration/ Expiracion the CDL *
Home Phone / Hogar *

Area Code Phone Number
Cell Phone / Celular *

Area Code Phone Number
Work / Trabajo

Area Code Phone Number
Email *
example@example.com
ADDRESS FOR PAST 3 YEARS / DIRECCION PASADOS 3 ANOS
Address #1 / Direccion #1

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How Long / Tiempo
Address #2 / Direccion #2

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How Long / Tiempo
Do you have the legal right t o work in the U.S / Usted esta autorizado para trabajar en EU?

Yes/Si No
Are you presently working / Usted esta actualmente trabajando?

Yes/Si No
If not, how long since last job / Si no, que tiempo hace desde su ultimo trabajo?

DRIVER APPLICATION

APLICACION DE CHOFER
ACCIDENT RECORD / LISTA DE ACCIDENTES

Accident record for past 3 years. Attach sheet if more space is needed / Lista de accidentes en que se haya visto envuelto en los ultimos 3 anos:
ACCIDENT 1 / ACCIDENTE 1 :
DATE / FECHA
TYPE OF ACCIDENT / TIPO DE ACCIDENTE
FATALITIES / MUERTOS
INJURIES / HERIDAS
ACCIDENT 2 / ACCIDENTE 2 :
DATE / FECHA
TYPE OF ACCIDENT / TIPO DE ACCIDENTE
FATALITIES / MUERTOS
INJURIES / HERIDAS
ACCIDENT 3 / ACCIDENTE 3:
DATE / FECHA
TYPE OF ACCIDENT / TIPO DE ACCIDENTE
FATALITIES / MUERTOS
INJURIES / HERIDAS
Traffic convictions and forfeitures for the past 3 years (other than parking violations) / Violaciones de transito en los ultimos 3 anos (violaciones que no sean de parqueo):
LOCATION / LUGAR #1
DATE / FECHA
CHARGE / TIPO DE MULTA
PENALTY / PENALIDAD
LOCATION / LUGAR #2
DATE / FECHA
CHARGE / TIPO DE MULTA
PENALTY / PENALIDAD
LOCATION / LUGAR #3
DATE / FECHA
CHARGE / TIPO DE MULTA
PENALTY / PENALIDAD
TO BE READ AND SIGNED BY APPLICANT

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. I 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. As a commercial CDL driver I hereby release employers, schools or persons from all liability in responding to inquiries in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview (s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company, as permitted by Law

PARA SER LEIDO Y FIRMAD OF POR EL APLICANTE

Esto certifica que esta applicacion ha sido completada por mí, y que toda la information dada aquí a mi entender es correcta. Yo autorizo a que se investige mi pasada medico, de empleado, historia de manejo y violaciones y otras cosas que sean relacionadad a este empleo que estoy siendo considerado como chofer comercial CDL. Si soy contratado entiendo que puedo ser despedido si yo he proveido información falso en esta aplicación. También entiendo que estoy requerido a obedecer la regulaciones de esta compañía permitidas por la Ley.
Today's Date *

Month Day Year
Date
Signature / Firma: *

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10 YEARS REQUIRED
DRIVER WORK HISTORY / HISTORIA DE TRABAJO DE CHOFER
Name

First Name Last Name
Date / Fecha

Month Day Year
Date
Company applying to / Compania a que aplica:
WORK HISTORY / HISTORIA DE TRABAJO

All driver's applicants to drive in intra or interstate commerce must provide the following information on all work during the preceding 10 years. Please complete the following by date order including those date periods in which you were not woorking or worked as a sole proprietor. / Todos los choferes que aplican a manejar vehiculos comerciales en el estado or fuera del estado, tienen que proveer la siguiente informacion relacionada a sus trabajos anteriores. Por favor complete la siguiente informaciaon en orden cronologico incluyendo los periodos de tiempo en que usted estuvo desempleado or trabajo por cuenta propia.

Which is the exact date of your first job in the US / Cual es la fecha exacta en que comenzo a trabajar en EE.UU ?
Date / Fecha

Month Day Year
Date
Please list your work history beginning with the most recent / Por favor indique su historia de trabajo comenzando por el mas reciente.
From Date / Desde Fecha

Month Day Year
Date
To Date / Hasta Fecha

Month Day Year
Date
Unemployed / Desempleado Worked for Company / Trabaje para una compania Self-Employed / Trabaje por cuenta propia
Were you subject to Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Estuvo sujeto a las Regulaciones des Departamento Federal de Seguridad de Transporte mientras trabajo con su previo empleador?

Yes / SI No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40? / Su previa posicion como conductor bajo aluno de los modos regulados por el DOT estuvo sujeto al requerimiento de examenes de alcohol y drogas como es requerido en 49 CFR part 40?

Yes / Si No
Company / Compania
Position Held / Posicion
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Reason for leaving / Razon de Renuncia
Contact Person / Supervisor
Contact Phone Number

Area Code Phone Number
Fax / Fax

Area Code Phone Number
Today's Date

Month Day Year
Date
Signature / Firma *

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DOT MANDATED DRIVER'S ACKNOWLEDGEMENT OF LOGS PROGRAM

This internal rule applies to all Owner Operators, and Drivers operating under the below mentioned carrier. This company rule mandates the following:

1- All logs MUST be turned in to the carrier company; including off duty date logs

2- Logs MUST be toally completed as per DOT requirements including compliance with driving and on duty hours.

3- Copies of all supportive documentation such as fuel and toll receipts MUST also be turned in to the carrier for false log verificaion.

As per company rule any violation of this mandated regulation could represent grounds for disciplinary acions including the termination of our services within the company.
Name

First Name Last Name
CDL Number
Carrier's Name
Date

Month Day Year
Date
Signature *

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PROGRAMA DOT MANDATORIO DE LOGS - RECONOCIMIENTO DEL CHOFER

Esta regla de la compania aplica a todos los Duenos Operadores y Choferes operando bajo esta compania. Esta regulacion dicta lo siguiente:

1- Todos los logs TIENEN que ser entregados a la compania; incluyendo aquellos por los dias en que usted no a trabajado

2- Los logs TIENEN que ser completados como la dicta las regulaciones del DOT teniendo en cuenta las horas permitidas de manejo y trabajo.

3- Copias de recibos de petroleo y peaje TIENEN que ser entregados como parte de la documentacion de sus logs.

Como regla de la compania cualquier violacion de este reglamento podria representar motivo de acciones desciplinarias, incluyendo la terminacion de nuestro servicios dentro de la compania.
Nombre del Chofer

First Name Last Name
Numero de CDL
Compania
Date

Month Day Year
Date
Signature *

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MOTOR VEHICLE DRIVER'S CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every drive who operates in intrastate, interstate, or foreigh commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in part 391 apply to every driver who operates in interstate commerce and operates and vehicle weighint 10,001 pounds or more , can transport more than 15 people, or transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Part 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987.

They are as follows:

1. POSSESS ONLY ONE LICENCE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license.

If you have more than one license, keep the license from your state of residence and return the additionals licenses to the states that issued them. DESTROYING a license has been lost, stolen or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state.

2. NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the next business day of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (ther than parking), you must report it wihin 30 days to: 1) your employing motor carrier , and 2) the state that issued your license (if the violation occurs in a state other than the one which issued your license) The notification to both the employer and state must be in writing.

The following license is the only one I will possess:
Driver's Licence No:
State:
Expiration Date:
DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.
Name

First Name Last Name
Signature *

Clear
Date

Month Day Year
Date
Notes

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CERTIFICATION OF VIOLATIONS / ANNUAL REVIEW OF DRIVING RECORD

MOTOR CARRIER INSTRUSTION: Each motor carrier shall at leases once every 12 months, require each driver to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only of which the driver has been convicted, or on account of which he/she has forfeited bod or collateral during the preceding parking) 12 months (section 391.27). Drivers who have provided information required by section 383.31 need not repeat that information on this form.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (section 391.27).
Driver's Name: Name Social Security No.: SS# Date of Service:   Date
License No.   Lic number   State      Expiration:   Date  Home Terminal:
I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.
If you have had no violations check this box - None

DATE - OFFENSE -LOCATION -TYPE OF VEHICLE OPERATED
Date   -   Offense   -   Location  -   Type of Vehicle
Date   -   Offense#2   -   Location#2  -   Type of Vehicle#2
Date   -   Offense#3   -   Location#3  -   Type of Vehicle#3
Date   -  Offense#4 -   Location#4 -   Type of Vehicle#4
Date  -   Offense#5  -   Locaion#5 -   Type of Vehicle#5

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under part 383) required to be listed during the pas 12 months.
Driver's Signature:

Clear
Date

Month Day Year
Date
COMPLETED BY MOTOR CARRIER – ANNUAL REVIEW OF DRIVING RECORD

MOTOR CARRIER INSTRUSTIONS: Review the certification of Violations listed above and other information described in section 391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below.
I hereby reviewed the driving record of the above named driver in accordance with section 391.25 and find that he/she (check one)

Meets Minimum Requirements of safe driving Is disqualified to drive a motor vehicle pursuant to Section 391.15 Does not adequately meet satisfactory safe driving performance
Action taken with driver:
Reviewed by:      Title :
Signature:   Signature   Date:   Date
Motor Carrier:

AUTORIZATION TO OBTAIN BACKGROUND INFORMATION

For as long as i am operating for the undernamed carrier company, I the undersigned, have authorized the Simplex Group, its agents and representatives, to obtain the following information:
- Past Employment References (skills, behavior, experience, drug & alcohol tests) (as per Section 391.23)
- Driving Record History
- Criminal Background Records
I understnad that any information obtained as a result of this release will be provided to the under named carrier company for hiring eligibility based on DOT regulation under part 391 of 49CFR.
Driver
Company
Social Security
CDL Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Signature *

Clear
Date

Month Day Year
Date
AUTORIZACION PARA OBTENER INFORMACION DE RECORDS

yo el abojo firmante autorizo a The Simplex Group, sus agentos, representantes, como tambien a la compania de transporte las siguiente informacion. Esta autoriacion estara vigente mientras to este operando para la compania de transporte mencionada en esta forma:
- Referencias de empleos anteriores (habilidades, comportamiento, experiencia, pruebas de drogas y alcohol) (por Section 391.23)
- Driving Record History
- Criminial Backgroud Records
Yo entiendo que cualquier informacion obtenida como resultado de esta autorizacion sera dada a la compania transportista paral la cual yo estoy aplicando. El resultado sera usado para determinar la aprobacion de su aplication basada en la regulacion de DOT bajo parte 391 de 49CFR.
Chofer
Compania
Seguro Social
CDL
Direccion

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Firma *

Clear
Fecha

Month Day Year
Date

ACKNOWLEDGEMENT OF PAS ON-DUTY HOURS/
DECLARACION DE PASADAS HORAS DE TRABAJO
Driver / Chofer
Date / Fecha

Month Day Year
Date
Seguro Social
CDL # / CDL
Company / Compania
I, the undersigned; certify that over the last (7) days, I have worked the following hours / Yo, el abajo firmante, certifico que en los ultimos (7) dias he estado trabajando las siguientes horas:

Days ago / Dias Atras

	1 Yesterday / Ayer	2 Days ago / Dias Atras	3 Days ago / Dias Atras	4 Days ago / Dias Atras	5 Days ago / Dias Atras	6 Days ago / Dias Atras	7 Days ago / Dias Atras	TOTAL
HOURS WORKED / Horas the trabajo

Are you currently working for another company?

Yes No
Will you be engaged in work activities prior to being dispatched by this company?

Yes No
I I hereby certify that the information given above is correct to the best of my knowledge and that I was relieved from my past employer at
Time: blanks Date: blank Signature Signature
En estos momentos usted esta trabajando para otra compania?

Si No
Mienetras que usted espera ser despachado de viaje por esta compania usted va trabajar en otro lugar?

Si No
Yo certifio que la informacioi que he brindado en este documento es correcta y que refleja cuando fue la ultima vez que trabaje
Hora: blanks Fecha: blank Signature Signature

DRIVER ACKNOWLEDGEMENT OF SUBSTANCE ABUSE TESTING POLICY/
RECONOCIMIENTO PORT PARTE DEL CHOFER POLITICA DE PRUEBAS DE ALCOHOL Y DROGAS

By DOT regultions no one is permitted to drive a commercial motor vehicle until theyhave signed, dated and returned this form.

Substance Abuse Policy. I also acknowledge that I can contact the management of the carrier company at Controlled Substance Abuse Policy. I also acknowledge that I can contact the management of the carrier company at anytime regarding any questions I may have concerning such company policy. I undertand that the terms described in this policy may be altered, amended or changed at any time to comply with the Federal DOT Regulations under Part 382 and its implementing regulations, with or withough prior notice. I furgher understand that any violtaion of thsi policy my subject me to discipline, up to and including termination.
Por ley del Departamento de Transporte no se permite a ninguna persona operar un vehiculo comercial sin antes haber firmado, fechando y entregado esta forma.

Yo reconozco que tengo el derecho a obtener una copia de la Politica de Drogas y Alcohol de la compania para la cual voy a trabajar. Tambien reconozco que puedo contactar a la administracion de la compania para hacer cualquier pregunta relacionada a la politica de la compania antes mencionada. Entiendo que los terminos descritos en esta politica de la compania pueded ser sin previo aviso, alterado, cambiados en cualquier momento para cumplir con las regulaciones federales del Departamento de Transporte en su parte 382 de acuerto a las regulaciones. Entiendo que si violo esta politica de la compania pudiese estar sujeto a acciones discipinarias o despido inmediato.
Driver / Chofer
Company / Compania
Signature *

Clear
Date

Month Day Year
Date

RELEASE & DOCUMENTATION OF PRE-EMPLOYEMENT TESTING INFORMATION BY APPLICATION/ DRIVER REQUIRED BY PART 40.25(J).

Part 40.25(j) requires Employers to ask Applicant/Driver whether he/she has tested positive or refused to tet on any Pre-employement alcohol or drug test administered by an Employer to which the Aplicant/Driver applied but did not obtain safety sensitive transportation work covered by DOT agency alcohol and drug testing rules during the past two (2) years.

Regulacion Part 40.25(j) requiere a companias de transporte preguntar al aplicante/chofer, si en los ultimos dos (2) anos, el/ella a tenido alguna vez un resultado positivo en una prueba de Pre-Empleo Alcohol y/o Drogas por el cual no haya obtenido empleo para una posiciaon en una compania de transporte, la cual sea regulada por el Departamento de Transporte (DOT).
Name

First Name Last Name
Date

Month Day Year
Date
Seguro Social
Applicant must answer the items listed below / Aplicante debe de contestar las siguientes preguntas
During the past two (2) years have you tested positive on a Pre-employement alcohol or drug test administered by Employer to which you applied for but did not obtain a safety sensitive transportation work covered by Department of Transportation (DOT) drug and alcohol testing rules? / Durante los ultimos dos (2) anos, usted ha teido un resultado positivo en una prueba de alcohol y/o drogas de Pre-Empleo, en el cual la prueba haya sido administradapor una compania el la cual usted aplico para una posicion de chofer regulada por el Departamento de Transporte (DOT)
Yes / Si No
During the past two (2) years have you refused to test on a Pre-Employment alcohol or drug test administered by Employer to which you applied for but did not obtian a safety sensitive transportation work covered by the Department of Transportation (DOT) drug and alcohol testing rules? / Durante los ultimos dos (2) anos, usted se a negado a tomar una prueba de alcohol y/o drogas de Pre-Empleo, en el cual la prueba hubiese sido administrada por una compania en la cual usted aplico para una posicion de chofer regulada por el Departamento de Transporte (DOT).
Yes / Si No
If you answered YES to either of the questions above, pleas provide documentation of your successful completion of the return-to-duty process required by part 40 subpart O. / Si usted contesto "Si" a alguna de las preguntas anteriores, por faor provea la documentacion necesaria que verifique que usted completo los requerimientos necesarios para regresar al trabajo segun la egulacion Part 40 subpart O.
Name / Nobre

First Name Last Name
Signature *

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Date

Month Day Year
Date
Witness / Testigo

First Name Last Name
Record keeping requirements: If "YES" to either question, retain for 5 years. If "No" to both questions, discard after employement terminates.

FAIR CREDIT REPORTING AT DISCLOSURE STATEMENT /
REGULACION DE INFORMACION SOBRE LA IGUALDAD DE REPORTES DE CREDITO
Name

First Name Last Name
Seguro Social
Company / Compania
Date / Fecha

Month Day Year
Date
In accordance with the provisions of section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitile D, Chapter I of Public law 104-208), you are being informed that reports verifying your prevous drug and alcohol test results, your driving record, a background check and a credit check may be obtainned for employement evalutaion purposes.
Signature *

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De acuerdo con las reglas de la seccion 604(b)(2)(a) de la ley de Credito al Consumidor, Ley Publica 91-508, y amendada por la Ley de Reportes de Credito del Consumidor de 1996 (Titulo II, Subtitulo D, Capitulo I Ley Publica 104-208), usted esta siendo informado que la verdificacion por parte nuesra de sus historial de resultados de drogas y alcohol a los cuales usted se ha sometido, historial de violaciones de trafico en su licencia de conduccion, historial criminal y reporte de historial de credito es solamente con fines de su aplicacion para trabajar con la compania de transporte mencionda en este documento.
Firma *

Clear
Should be Empty:

DRIVER APPLICATION

DRIVER APPLICATION

DRIVER APPLICATION

10 YEARS REQUIRED

10 YEARS REQUIRED

10 YEARS REQUIRED

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