MAT II TRANSPORTATION DRIVER APPLICATION

MAT II TRANSPORTATION
- PO BOX 489 Junction City, OR 97448.
- Phone: (541)998-8955
- Fax: (541) 998-1544
- Email: pdispatch@mattrans.com
APPLICATION FOR EMPLOYMENT
APPLICANT INFORMATION
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date:

MonthDayYear
Date
Social Security Number:
Phone
Email
example@example.com
Position Applying For: Flatbed Driver
Date Available:

MonthDayYear
Desired Salary:
Are you a Citizen of the United States?

YesNo
If no, are you authorized to work in the U.S?

YesNo
Have you ever worked for this company?

YesNo
If so, when?
Have you ever been convicted of a felony involving a CMV?

YesNo
If yes, please explain:
Education
Name of High School:
Years Attended: From
To:
Did you graduate?

YesNo
College: (If attended)
Years Attended: From
To:
Did you graduate?

YesNoDegree
Other Education:
Years Attended: From
To:
Did you graduate?

YesNoDegree
MILITARY SERVICE
Branch:
Years: From
To:
Rank at discharge:
Type of discharge:
If other than honorable, please explain:
PERSONAL REFERENCE
Full Name:
Relationship:
Phone Number
Please enter a valid phone number.
Company:
PREVIOUS EMPLOYMENT
Current Employer Name:
Phone:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor:
Years worked for: From
To:
Responsibilities:
Reason for leaving:
Starting Salary:
Ending Salary:
May we contact your current employer for a reference?

YesNo
Were you subject to the FMCSRs while employed?

YesNo
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol testing requirements of 49 CFR part 40?

YesNo
Previous Employer #1 Name:
Phone:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor:
Years worked for: From
To:
Responsibilities:
Reason for leaving:
Starting Salary:
Ending Salary:
Were you subject to the FMCSRs while employed?

YesNo
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol testing requirements of 49 CFR part 40?

YesNo
Previous Employer #2 Name:
Phone:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor:
Years worked for: From
To:
Responsibilities:
Reason for leaving:
Starting Salary:
Ending Salary:
Were you subject to the FMCSRs while employed?

YesNo
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol testing requirements of 49 CFR part 40?

YesNo
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my immediate release.
Signature:

Clear
Date

MonthDayYear
Date
REQUEST FOR CHECK OF DRIVING RECORD
NOTE: This form may only be used in states that do not require a specific form. CAUTION: When using a third party to request background information on applicants or existing employees - such asmotor vehicle records, information from previous employers, criminal records, or credit history - you are subject to Fair Credit Reporting Act. (FCRA) and State consumer reporting laws. Under FCRA, the third-party vendor is considered a consumer reporting agency (CRA) and the employee background information is a consumer report. Before you can obtain a consumer report from CRA, you must have authorization from the applicant or employee to conduct the check. You must also provide a copy of the Federal Trade Commission's notice called "A Summary of You Rights Under the Fair Credit Reporting Act." The notice, disclosure, and authorization are not included in this file, and some state laws have additional requirements. Consult with your CRA on the need and use of such documents.
I hereby authorize you to release the following information to MAT II TRANSPORTATION, PO BOX 489 JUNCTION CITY, OR 97448.
Signature

Clear
Date

MonthDayYear
Date
I also hereby certify that this report request and the above drivers release notice meet the definiton of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994 (public law 103-322, Title XXX, Section 300002(a)).
Requestor Digital/Electronic Signature:

First NameLast Name
Date

MonthDayYear
Date
9. TO: RIS INSURANCE SERVICES
DEAR SIR/MADAM:

The Following named person has made application with our company for the position of In accordance with Section 391.23, Federal Department of Transportation Regulations, please furnish the undersigned with the applicant's driving record for the past three yearsThe following named person is employed with our company in the position of In accordance with Section 391.25, Federal Department of Transportation Regulations, please furnish the undersigned with the employee's driving record for the past year.
NAME OF DRIVER:
ADDRESS:
FORMER ADDRESS:
DATE OF BIRTH:

MonthDayYear
Date
SSN:
CDL:

YesNo
YEARS CDL DRIVING EXPERIENCE:
LICENSE Number:
STATE ISSUED ID Number:
10. REQUESTED BY:
MAT II TRANSPORTATION

PO BOX 489, JUNCTION CITY, OR 97448
(Printed Name)
(Title)
(Signature)
Privacy Notification: A credit report or other investigation report about you, including a motor vehicle report, may be requested in connection with application for employment. Any information which we have or may obtain about you will be treated confidentially. However, this information as well as other personal or privileged information subsequently corrected, may, under certain circumstances be disclosed without prior authorization to third parties, such as to our affiliated companies for claim handling, servicing. And underwriting.

You have the right to see personal information collected about you, and you have the right to correct any information that may be wrong.

If you are interested in obtaining description of our information practices, and our rights regarding information we collect, ask your employer.
PREVIOUS EMPLOYEE SAFETY PERFORMANCE HISTORY
I, (Name of Previous Employee):
Social security:
Date of birth:

MonthDayYear
Date
hereby authorize, Company Name:
Phone:
Contact Name:
Email:
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax:
To release and forward the infomation requested below pursuant to a request for Previous Employee Safety Performance History, including my Alcohol and Controlled Substances Testing records within the previous 3 years. This response is being provided to the Prospective Employer noted below in compliance with the Federal Motor Carrier Safety Regulations, 49 CFR §§40.25 and 391.23. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of recipt.
Signature

Clear
Dated:

MonthDayYear
Date
PROSPECTIVE EMPLOYER INFORMATION
Company Name:
Contact Name:
Phone:
Email:
example@example.com
Address:
Fax:
FORMER EMPLOYEE WORK HISTORY
Employed from:
To:
as a
Check here if driver was not DOT regulated:
Did he/she drive a motor vehicle for you?

YesNo
If yes, please specify which type:

Straight truckTractor-Semi trailerBusCargoTankDoubles/triplesFlatbed
Reason for leaving employ:

DischargedResignationLay offMilitary Duty
Is the previous employee eligible for rehire?

YESNO
ACCIDENT HISTORY
Check here if there is no accident register data for this applicant. Complete the following for any accidents included on your accident register (§390.15(b that involved the applicant in the previous 3 years.
Date of accident:
Location of accident:
No. of Injuries:
No. of Tows:
No. of Fatalities:
No. of Fatalities:
Hazmat Spill?
Date of accident:
Location of accident:
No. of Injuries:
No. of Fatalities:
No. of Tows:
Hazmat Spill?
Date of accident:
Location of accident:
No. of Injuries:
No. of Fatalities:
No. of Tows:
Hazmat Spill?
DRUG AND ALCOHOL HISTORY
Check here if applicant was not subject to DOT testing requirements under 49 CFR Part 40 while employed by you.
In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previous employers in the previous 3 years.
Applicant was subject to DOT testing requirements from:
to
In the past 3 years:

Has the named applicant violated any of the drug and/or alcohol prohibitions under 49 CFR Part 40 or Subpart B of Part 382, including:
An alcohol test with a result of 0.04 or higher alcohol concentration.

YesNo
A controlled substances test result of positive, adulterated, or substituted.

YesNo
A refusal to submit to a random, post-accident, reasonable-suspicion, or follow-up controlled substances or alcohol test. Alcohol use while performing or within 4 hours before performing safety-sensitive functions. Alcohol use after an accident, in violation of $382.303.

YesNo
Alcohol use while performing or within 4 hours before performing safety-sensitive functions.

YesNo
Alcohol use after an accident, in violation of §382.303.

YesNo
Controlled substances use while on duty, except as allowed under $382.213.

YesNo
This person violated a DOT drug and alcohol regulation and completed a SAP prescribed rehabilitation program, including return to duty and follow-up tests. If YES, documentation enclosed.

YesNo
This person, after successfully completing a SAP's rehabilitation program remained in our employ but subsequently had an alcohol test result of 0.04 or greater, a verified positive drug test, or refused to take a test.

YesNo
Completed by:
Date

MonthDayYear
Date
Title:
Telephone
Digital/Electronic Signature:

First NameLast Name
Should be Empty:

MAT II TRANSPORTATION

APPLICATION FOR EMPLOYMENT

APPLICANT INFORMATION

Position Applying For: Flatbed Driver

Education

MILITARY SERVICE

PERSONAL REFERENCE

PREVIOUS EMPLOYMENT

DISCLAIMER AND SIGNATURE

REQUEST FOR CHECK OF DRIVING RECORD

10. REQUESTED BY:

PREVIOUS EMPLOYEE SAFETY PERFORMANCE HISTORY

PROSPECTIVE EMPLOYER INFORMATION

FORMER EMPLOYEE WORK HISTORY

ACCIDENT HISTORY

DRUG AND ALCOHOL HISTORY