APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT
Applicant Full Name*
Position Applying For*
Current Address*
Social Security No*
Date of Birth*

MonthDayYear
Date
Telephone*
Format: (000) 000-0000.
Email*
example@example.com
Date Of Application

MonthDayYear
Date

ADDRESS HISTORY
This section displays all previous addresses for the past 3 years, most recent first.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
Stop Date*

MonthDayYear
Date
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Start Date
  
  MonthDayYear
  Date
- Stop Date
  
  MonthDayYear
  Date
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Start Date
  
  MonthDayYear
  Date
- Stop Date
  
  MonthDayYear
  Date

EMPLOYMENT HISTORY
Please complete all information regarding prior employers during the last three years. If you are applying to operate a Commercial Motor Vehicle (GVWR of 10,001 lbs. or more, ability to transport 8 or more people, or any vehicle requiring placarding for hazardous materials), please include complete information regarding prior employers for the last 10 years for whom you operated such vehicles. Please start with your most recent prior employer.
Employer #1*
Position*
Start Date*

MonthDayYear
Date
Stop Date

MonthDayYear
Date
Company's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Salary
Contact number*
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer*
Was your position "safety sensitive" requiring Part 40 drug and alcohol testing*
- Employer #2
- Position
- Start Date
  
  MonthDayYear
  Date
- Stop Date
  
  MonthDayYear
  Date
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Salary
- Contact number
- Reason for Leaving
- Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer
- Was your position "safety sensitive" requiring Part 40 drug and alcohol testing
- Employer #3
- Position
- Start Date
  
  MonthDayYear
  Date
- Stop Date
  
  MonthDayYear
  Date
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Salary
- Contact number
- Reason for Leaving
- Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer
- Was your position "safety sensitive" requiring Part 40 drug and alcohol testing
- Employer #4
- Position
- Start Date
  
  MonthDayYear
  Date
- Stop Date
  
  MonthDayYear
  Date
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Salary
- Contact number
- Reason for Leaving
- Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer
- Was your position "safety sensitive" requiring Part 40 drug and alcohol testing
- Employer #5
- Position
- Start Date
  
  MonthDayYear
  Date
- Stop Date
  
  MonthDayYear
  Date
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Salary
- Contact number
- Reason for Leaving
- Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer
- Was your position "safety sensitive" requiring Part 40 drug and alcohol testing
- Employer #6
- Position
- Start Date
  
  MonthDayYear
  Date
- Stop Date
  
  MonthDayYear
  Date
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Salary
- Contact number
- Reason for Leaving
- Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer
- Was your position "safety sensitive" requiring Part 40 drug and alcohol testing

ADDITIONAL CONSIDERATIONS
Additional considerations as provided by the applicant.
Has artificial and/or prosthetic limb?*
Has vision impairment?*
Has hearing impairment?*
Has a seizure disorder?*
Has diabetes?*

DRIVER'S REVIEW AND RECEIPTS
I acknowledge that V Line Inc has provided me with written instructions regarding my rights as defined in Part 391.23(i)-(j) of the Federal Motor Carrier Safety Regulations. I have reviewed these materials which include information on the following:
- Right to Review Information – I have the right to review the information provided by my previous DOT-regulatedemployer(s).
- Right to Request Corrections – I have the right to request corrections to information that my previous DOT-regulatedemployer(s) provides, which I believe contains errors.
- Right to Rebut Information – I have the right to rebut the information provided by my previous DOT-regulated employer(s).
I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other relatedmatters as may be necessary in arriving at an employment decision of the Federal Motor Carrier Safety Regulations.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will becontacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e).
Signature

Clear

AGREE TO PRE-EMPLOYMENT SCREENING PROGRAM
I authorize V Line Inc to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safetyrecord and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information includingcrash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release ofinformation 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 tocorrect any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request tohttps://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understandmy request will be forwarded by the DataQs system to the appropriate State for adjudication. I understand that any crash or inspection in which I wasinvolved 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 Iwas a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or withoutviolations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will alsoappear, 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 andAuthorization, 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.
Signature

Clear

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK
I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of“consumer reports” and/or “investigative consumer reports” by V Line Inc at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by V Line Inc. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original
Signature

Clear

DRIVER'S AUTHORIZATION TO RELEASE INFORMATION
I, full name* hereby authorize to release information that verifies my previous employment and Safety Performance History as required by 49 CFR Part 391.23 within 30 days of receiving this authorization. By signing this release I acknowledge that the information released will be used by the Prospective Employer named below when making their hiring decision and will be kept confidential.
Name*

First NameLast Name
Your Signature*

Clear
Driver's CDL#*
Today's Date*

MonthDayYear
Date

UPLOAD DOCUMENTS
Upload any additional documents to accompany your application. Please include your CDL, medical card, social security card, and certificates (if there are any).

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APPLICATION FOR EMPLOYMENT

ADDRESS HISTORY

EMPLOYMENT HISTORY

ADDITIONAL CONSIDERATIONS

DRIVER'S REVIEW AND RECEIPTS

AGREE TO PRE-EMPLOYMENT SCREENING PROGRAM

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

DRIVER'S AUTHORIZATION TO RELEASE INFORMATION

UPLOAD DOCUMENTS