ABIDE TRUCKING, INC DRIVER APPLICATION

DRIVER EMPLOYMENT APPLICATION
ABIDE TRUCKING, INC
Complete in Full or Application will not be considered
APPLICANT INFORMATION
Name*

FIRST NAMEMIDDLE NAMELAST NAME
PHONE*
EMAIL*
example@example.com
DATE OF BIRTH*

MonthDayYear
Date
SOCIAL SECURITY #
DATE OF APPLICATION

MonthDayYear
POSITION APPLIED FOR*
DATE AVAILABLE FOR WORK*

MonthDayYear
Do you have legal right to work in the United States?*

YESNO
PREVIOUS THREE YEARS RESIDENCY
Current:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years at Residence
Check if Mailing Address is same

YESNO
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PREVIOUS:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years at Residence
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years at Residence
LICENSE INFORMATION
No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21 I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.
STATE*
LICENSE NUMBER*
TYPE/CLASS*
ENDORSMENTS*
Put NA if not applicable
EXPIRATION DATE*
Put NA if not applicable
PREVIOUSLY HELD LICENSES
Have you held a previous license?

YesNo
STATE
LICENSE NUMBER
TYPE/CLASS
ENDORSEMENTS
EXPIRATION DATE
DRIVING EXPERIENCE
DO YOU HAVE EXPERIENCE WITH A STRAIGHT TRUCK?

YESNO
TYPE OF EQUIPMENT
DATES FROM   Date
DATES TO   Date
APPROX, # of Miles Total   Number
DO YOU HAVE EXPERIENCE WITH A TRACTOR & SEMI TRAILER?*

YESNO
TYPE OF EQUIPMENT
DATES FROM   Date
DATES TO   Date
APPROX, # of Miles Total   Number
DO YOU HAVE EXPERIENCE WITH A TRACTOR & 2 SEMI TRAILER?*

YESNO
TYPE OF EQUIPMENT
DATES FROM   Date
DATES TO   Date
APPROX, # of Miles Total   Number
DO YOU HAVE EXPERIENCE WITH A TRACTOR & TANKER?*

YESNO
TYPE OF EQUIPMENT
DATES FROM   Date
DATES TO   Date
APPROX, # of Miles Total   Number
ACCIDENT RECORD FOR THE PAST 3 YEARS

Check this box if none
List most recent first
DATE   Date
NATURE OF ACCIDENT (Head-on, rear-end, upset, etc)blank
# of Fatalites
# of Injuries
Chemical Spills   YES   NO
DATE   Date
NATURE OF ACCIDENT (Head-on, rear-end, upset, etc)blank
# of Fatalites
# of Injuries
Chemical Spills   YES   NO
DATE   Date
NATURE OF ACCIDENT (Head-on, rear-end, upset, etc)blank
# of Fatalites
# of Injuries
Chemical Spills   YES   NO
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

Check this box if none
DATE CONVICTED   Date
VIOLATIONblank
STATE OF VIOLATION
PENALTY
DATE CONVICTED   Date
VIOLATIONblank
STATE OF VIOLATION
PENALTY
DATE CONVICTED   Date
VIOLATIONblank
STATE OF VIOLATION
PENALTY
DATE CONVICTED   Date
VIOLATIONblank
STATE OF VIOLATION
PENALTY
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*

YESNO
If yes, explain:
Has any license, permit, or privilege ever been suspended or revoked?*

YESNO
If yes, explain:
EMPLOYMENT HISTORY
The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.

Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.
CURRENT (MOST RECENT) EMPLOYER
NAME*
PHONE*
ADDRESS*
POSITION HELD*
FROM MO/YR*
TO MO/YR*
REASON FOR LEAVING*
SALARY*
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*

YESNO
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*

YESNO
SECOND (MOST RECENT) EMPLOYER
NAME
PHONE
ADDRESS
POSITION HELD
FROM MO/YR
TO MO/YR
REASON FOR LEAVING
SALARY
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

YESNO
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

YESNO
THIRD (MOST RECENT) EMPLOYER
NAME
PHONE
ADDRESS
POSITION HELD
TO MO/YR
TO MO/YR
REASON FOR LEAVING
SALARY
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

YESNO
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

YESNO
EDUCATION
HIGH SCHOOL
NAME: blanks
LOCATION: blank
COURSE OF STUDY
YEARS Completed
Did you Graduate?
YES   NO
COLLEGE
NAME: blanks
LOCATION: blank
COURSE OF STUDY
YEARS Completed
Did you Graduate?
YES   NO
OTHER QUALIFICATIONS
Please list any other qualifications that you have and which you believe should be considered.
TO BE READ AND SIGNED BY APPLICANT
I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. 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 for those previous employers to resend the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

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. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.
Applicant Signature*

Clear
I hereby authorize any employer, law enforcement agency, state agency, institution, or privateinformation bureau that has any record of knowledge of my worker’s compensation claims,motor vehicle operation history, or criminal history, to provide Abide Trucking any such information. This authorization is included, buy not limited to birth, court, criminal, driving, educational, financial, immigration, legal, medical, military, and naturalization records. This authorization shall be valid for one (1) year from the date signed and a photographic copy of authorization shall be as valid as the original. Permission is granted for information to be released by any state agency including, but not limited to, Department of Labor, Workers Compensation Division. Under the Americans With Disabilities Act, we will not be checking with the Workers Compensation Division until after I have an offer of employment.

I waive any provision impeding the release of this information, and agree to provide any information necessary for the release of this information above and beyond that provided on the employment application. According to the Fair Credit Reporting Act, I as entitled to know if employment is denied because of information obtained by my prospective employer from a Consumer Reporting Agency. I will be so advised and given the name of the reporting agency for more information.
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Applicant Name (printed)*
Should be Empty:

DRIVER EMPLOYMENT APPLICATION

ABIDE TRUCKING, INC

APPLICANT INFORMATION

PREVIOUS THREE YEARS RESIDENCY

Current:

PREVIOUS:

LICENSE INFORMATION

PREVIOUSLY HELD LICENSES

DRIVING EXPERIENCE

EMPLOYMENT HISTORY

CURRENT (MOST RECENT) EMPLOYER

SECOND (MOST RECENT) EMPLOYER

THIRD (MOST RECENT) EMPLOYER

EDUCATION

OTHER QUALIFICATIONS

TO BE READ AND SIGNED BY APPLICANT