APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT:

Qualification Application & Statistical Report -- (For DOT compliance Title 49 CFR 391)
This application is for ALL divisions within Accel Logistics, Inc. In the noted section, choose which position you are applying for (i.e. O/O, Company Driver, Admin Staff, Field Super, etc.)
BASIC INFORMATION
Name*

First NameMiddle NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at current address?*
Enter months and years
Phone Number*

Area CodePhone Number
Social Security Number*
Email*
Emergency Contact*
Enter name, phone number, and relationship
Please enter your previous addresses for the last seven years:
Include street address, city, state, zip code, and DATES
Have you ever been convicted of a crime? *
If yes, give offense, date, court, and place where offense occurred. Include felonies, misdemeanors. Do not list traffic convictions here. A conviction does not automatically bar employment.
Date of Birth*

MonthDayYear
Date
Date Available to Start*

MonthDayYear
Date
List any days and hours you are not able to work:
For Which Position Are You Applying?*
How did you hear about us?*
If you were referred, enter their name here. *** If a name is not listed here, any applicable bonuses will not be paid. *
Enter N/A if not referred
EDUCATION
Can you read English?*
Can you speak English?*
Can you write English?*
High School Name and Address
Did you graduate High School?
College Name and Address
Years Completed
Degree Achieved
Trade School Name and Address
Years Completed
Certification Achieved
List any foreign languages you can speak or write:
List any special equipment you can operate:
EMPLOYMENT HISTORY

List all employment history beginning with your current or most recent employer. For any unemployed or self-employed periods over 30 days, show date and location. Give full details for any discharge. When applying for a position as a commercial driver, DOT requires that you list a minimum of 10 years of employment history. Use only the tables necessary.

Previous Employment #1*

	Enter your response here:
Company Name
Company Address (include city, state, & zip)
Supervisor Name
Supervisor or Main Phone
First Day of Employment
Last Day of Employment
Starting Pay
Final Pay
Job Title / Classification
Duties Performed
Reason for Leaving
Were you subject to FMCSR? (non-drivers enter N/A)
Were you subject to D.O.T. drug & alcohol testing?
May we contact this employer?

Previous Employment #2

	Enter your response here:
Company Name
Company Address (include city, state, & zip)
Supervisor Name
Supervisor or Main Phone
First Day of Employment
Last Day of Employment
Starting Pay
Final Pay
Job Title / Classification
Duties Performed
Reason for Leaving
Were you subject to FMCSR? (non-drivers enter N/A)
Were you subject to D.O.T. drug & alcohol testing?
May we contact this employer?

Previous Employment #3

	Enter your response here:
Company Name
Company Address (include city, state, & zip)
Supervisor Name
Supervisor or Main Phone
First Day of Employment
Last Day of Employment
Starting Pay
Final Pay
Job Title / Classification
Duties Performed
Reason for Leaving
Were you subject to FMCSR? (non-drivers enter N/A)
Were you subject to D.O.T. drug & alcohol testing?
May we contact this employer?

Previous Employment #4

	Enter your response here:
Company Name
Company Address (include city, state, & zip)
Supervisor Name
Supervisor or Main Phone
First Day of Employment
Last Day of Employment
Starting Pay
Final Pay
Job Title / Classification
Duties Performed
Reason for Leaving
Were you subject to FMCSR? (non-drivers enter N/A)
Were you subject to D.O.T. drug & alcohol testing?
May we contact this employer?

Previous Employment #5

	Enter your response here:
Company Name
Company Address (include city, state, & zip)
Supervisor Name
Supervisor or Main Phone
First Day of Employment
Last Day of Employment
Starting Pay
Final Pay
Job Title / Classification
Duties Performed
Reason for Leaving
Were you subject to FMCSR? (non-drivers enter N/A)
Were you subject to D.O.T. drug & alcohol testing?
May we contact this employer?

Previous Employment #6

	Enter your response here:
Company Name
Company Address (include city, state, & zip)
Supervisor Name
Supervisor or Main Phone
First Day of Employment
Last Day of Employment
Starting Pay
Final Pay
Job Title / Classification
Duties Performed
Reason for Leaving
Were you subject to FMCSR? (non-drivers enter N/A)
Were you subject to D.O.T. drug & alcohol testing?
May we contact this employer?

Previous Employment #7

	Enter your response here:
Company Name
Company Address (include city, state, & zip)
Supervisor Name
Supervisor or Main Phone
First Day of Employment
Last Day of Employment
Starting Pay
Final Pay
Job Title / Classification
Duties Performed
Reason for Leaving
Were you subject to FMCSR? (non-drivers enter N/A)
Were you subject to D.O.T. drug & alcohol testing?
May we contact this employer?

Previous Employment #8

	Enter your response here:
Company Name
Company Address (include city, state, & zip)
Supervisor Name
Supervisor or Main Phone
First Day of Employment
Last Day of Employment
Starting Pay
Final Pay
Job Title / Classification
Duties Performed
Reason for Leaving
Were you subject to FMCSR? (non-drivers enter N/A)
Were you subject to D.O.T. drug & alcohol testing?
May we contact this employer?

If you are applying for a NON-DRIVING position, you have completed the application. Please scroll to the bottom to sign & submit.

If you are applying for a DRIVING position, you must continue this application answering the remaining questions in full. Incomplete applications will be discarded.
Click here to acknowledge understanding:*

Yes, I understand
DRIVERS LICENSE INFORMATION
Drivers License Number
State of License
Date you acquired your CDL

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Class
Restrictions
Endorsements
FIVE-YEAR MOTOR VEHICLE VIOLATIONS HISTORY

List ALL violations of motor vehicle laws or ordinances (other than parking violations) of which you have been convicted or forfeited bond or collateral during the previous five years. This list must include DWI's, DUI's, and violations received when operating a car, truck, motorcycle, or any other type of motor vehicle.

Motor Vehicle Violation #1

	Enter your response here:
Date of Violation
City & State of Violation
Type of Violation (For speeding, enter speed limit and speed at which you were cited)
CMV (enter "yes" or "no")

Motor Vehicle Violation #2

	Enter your response here:
Date of Violation
City & State of Violation
Type of Violation (For speeding, enter speed limit and speed at which you were cited)
CMV (enter "yes" or "no")

Motor Vehicle Violation #3

	Enter your response here:
Date of Violation
City & State of Violation
Type of Violation (For speeding, enter speed limit and speed at which you were cited)
CMV (enter "yes" or "no")

FIVE-YEAR ACCIDENT HISTORY

List ALL motor vehicle accidents in which you have been involved during the previous five years regardless of how minor. Give all dates, descriptions, and if any injuries or fatalities resulted.
If you have not had any accidents in the past five years, please click the radio button below to confirm such:

NO ACCIDENTS IN FIVE YEARS

Accident #1

	Enter your response here:
Date of Accident
Full Description of Accident
State of Accident
Number of Injuries
Number of Fatalities

Accident #2

	Enter your response here:
Date of Accident
Full Description of Accident
State of Accident
Number of Injuries
Number of Fatalities

Accident #3

	Enter your response here:
Date of Accident
Full Description of Accident
State of Accident
Number of Injuries
Number of Fatalities

OTHER DRIVING HISTORY
STRAIGHT TRUCK - Years & Months of Experience
STRAIGHT TRUCK - Explain type & size of vehicle
STRAIGHT TRUCK - Local or Road?

LOCALROAD
TRACTOR / TRAILER - Years & Months of Experience
TRACTOR / TRAILER - Explain type & size of vehicle
TRACTOR / TRAILER - Local or Road?

LOCALROAD
OTHER (BUS, TWIN TRAILER, ETC.) - Years & Months of Experience
OTHER (BUS, TWIN TRAILER, ETC.) - Explain type & size of vehicle
OTHER (BUS, TWIN TRAILER, ETC.) - Local or Road?

LOCALROAD
Have you been driving regularly in the last five years?
Please list all states, separated with a comma, that you have driven in over the last five years:
List any safety awards you have received:
Has your operator's, chauffer's, or CDL license ever been suspended and/or revoked; or, have you ever had an application for such license been denied and/or disqualfied?
Have you ever failed a random or pre-employment drug screen?
If yes, list the details. Give date, state, reason, length of suspension, and date of reinstatement:
NOTE TO DRIVER APPLICANTS

This application and report cannot be treated as confidential and will be available for copy, examination and investigation by any independent contractor who may consider employing you, or by any motor carrier for whom such Independent Contractor undertakes to perform transportation services. By executing this document, you expressly agree and authorize as follows: (1) The information given herein has been supplied for the purpose of securing safety clearance and qualification as a motor vehicle driver as required by Federal Motor Carrier Safety Regulations, in addition to the purpose of securing employment by an Independent Contractor. (2) A DOT physical examination and substance abuse test will be taken at the applicant’s own expense. (3) If safety clearance is secured, the first thirty days of such safety clearance shall be on a temporary or probationary basis, during which period, such qualification may be terminated without any recourse by applicant against any person. (4) The furnishing of the preceding information herein shall not obligate any Independent Contractor to employ the applicant in any capacity.
** ALL APPLICANTS: IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING

I understand and agree that, as part of the application process, information will be obtained from my former employer, including but not limited to the following: general driver identification and employment verification; information about any accidents in which I may have been involved, information regarding compliance with DOT alcohol and drug requirements, and information regarding any participation in substance abuse rehabilitation programs. I expressly consent to the disclosure of this information by my former employers. I understand that I have the right to: 1) review any of the information obtained from former employers; 2) have errors in the information corrected by former employers and have the corrected information re-sent; and 3) attach a written rebuttal statement to any information which I perceive to be inaccurate and which is the subject of a disagreement between me and former employers. I understand that if I desire to review information provided by a former employer, I must submit a written request at any time up to 30 days after being qualified or being notify of a denial of qualification. I understand that if I have no arranged to pick up the requested records within 30 days of the records being made available, I may have waived my right to review the records. I certify that this application and report was completed by me and that all entries on it, and information in it, are true and complete to the best of my knowledge, and I agree that any omission of any information requested in this application shall be valid reason for rejection of safety clearance and disqualification, or discharge if employed by the independent contractor. Furthermore, I agree to submit to a physical examination whenever requested during my possible qualification. I authorize a specified health facility to collect and analyze a sample of my body fluids for the purpose of drug/alcohol screening and the results of this test to be communicated to Accel Logistics Inc., 322 International Parkway, Arlington, TX, 76011.
Acknowledge understanding of paragraphs above by typing full legal name:*
FULL LEGAL NAME
Attach a photo of your drivers license, passport, or other government ID

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Attach a photo of your social security card

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If you would like to attach a resume to accompany your application, you may do so here. You must still complete the previous employment section.

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Signature*
Date*

MonthDayYear
Date
Should be Empty:

APPLICATION FOR EMPLOYMENT:

NOTE TO DRIVER APPLICANTS

** ALL APPLICANTS: IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING