Truck Driver Application Final

DRIVER APPLICATION
General Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Were you at this address 3 years or more*

YesNo
Please list prior 3 year addresses here and please be complete
Social Security Number*
Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Have you ever been known by any other name?

YesNo
Please list name
Explain ie; maiden name, name change
If hired, can you furnish proof you are eligible to work in the U.S.?*

YesNo
License Information
Have you held a VALID US license for the past 36 months?*

YesNo
License Class*
License Number*
State of Issue*
License expiration date*

MonthDayYear
Expiration date of DOT physical card

MonthDayYear
CDL Endorsements*

NoneTankerDoubles/TriplesHazmatX EndorsementTWIC
Hazmat expiration date

MonthDayYear
TWIC expiration date

MonthDayYear
Please list any licenses held in other states for the previous 5 years, include license numbers if you can.
Have you been to truck driving school?

YesNo
EMPLOYMENT HISTORY
Work History: Please list current, or most recent employment first
Start date*

MonthDayYear
Ending date*

MonthDayYear
Employer Name*
City, State*
Employer phone*

Area CodePhone Number
Position Held*
Reason for leaving*
Is this your current employer?*

YesNo
May we contact this employer at this time?*

YesNo
Was this a driving position?

YesNo
Type of truck
Type of trailer
Trailer length
Number of states driven
NEXT EMPLOYER
Start date

MonthDayYear
Ending date

MonthDayYear
Employer Name
City, State
Position Held
Reason for leaving
Employer phone

Area CodePhone Number
Was this a driving position?

YesNo
Type of truck
Type of trailer
Trailer length
Number of states driven
NEXT EMPLOYER
Starting date

MonthDayYear
Ending date

MonthDayYear
Employer Name
City, State
Position Held
Employer phone

Area CodePhone Number
Reason for leaving
Was this a driving position

YesNo
Type of truck driven
Type of trailer
Trailer length
Number of states driven
NEXT EMPLOYER
Start Date

MonthDayYear
End Date

MonthDayYear
Employer Name
City and State
Position
Employer Phone

Area CodePhone Number
Reason for leaving
Was this a driving position

YesNo
Type of truck driven
Type of trailer
Trailer length
Number of states driven
If you need additional space for past employment, please enter it here and include ALL information previously asked for.
Additional Information
Have you had any moving violations in the last 5 years?*

YesNo
If yes, please list City, County and State, month, year and nature of offense and any fines involved
Please list miles over limit for speeding
Has your license suspended ever been suspended?*

YesNo
If yes, please give date and length of supension. List reason why, city, county and state
List all details asked for
Have you had any accidents in the last 5 years?*

YesNo
If yes, please give date, explaination, city, county and state and if you received ticket/fine (amount)
Have you ever had a DUI, DWI, or OVI?*

YesNo
If yes, please list date of offense, jail time, fine and or suspension time.
We must have complete information to satisfy isusance carrier requirements.
Have you ever been convicted of a felony?*

YesNo
If yes, please give date and nature of offense, city, county, state and any fines and time served
Please list EVERYTHING asked for per isurance requirements
Have you ever been convicted of a misdemeanor?*

YesNo
If yes, please list date and nature of offense, city, county and state. also jail time, probation, or fines
Please list EVERYTHING asked for
Emergency contact information
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Relationship to you
Phone Number

Area CodePhone Number
Fair Credit Reporting Act-Disclosure Notice and Authorization Form
Driver Name*
Social Security*
Company
Date*

MonthDayYear
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, Subtitle D, Chapter I of Public Law 104-208), you are being informed that reports verifying your previous drug and alcohol test results, your driving record, a background check and a credit check may be obtained for employment evaluation purposes.
AUTHORIZATION TO OBTAIN BACKGROUND INFORMATIN
For as long as I am operating for the under named carrier company, I the undersigned, have authorized Capital Transportation, LLC, 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 understand 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.
Signature*

Clear
Motor Vehicle Record Request Form
I would like to request you to order a Motor Vehicle Record (MVR) for the following individual:
Driver's License Number*
State of Issue*
Date

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Individual: I understand that driving is a part of my job description, and I hereby give permission to Capital Transportation, LLC to access my motor vehicle records.
Signature*

Clear
PAST EMPLOYMENT SAFETY HISTORY REQUEST
FROM: Capital Transportation, LLC

501 New County Rd, Ste2, Secaucus, NJ 07094

PHONE: 551-233-8100, Please return by faxing to: 551-236-1815
The person named herein has applied to Capital Transportation, LLC for employment in a safety sensitive position.
Name of Applicant:   First Name   Last Name   SSN#:   Number
I, the listed applicant, hereby authorize the following company(s) to release all records of employment, including assessments of my job performance, ability, fitness and drug testing results to Capital Transportation, LLC. I hereby release the below listed company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing the following information to the above-mentioned company. The applicant’s signature on this form releases all liability of you and your company. Information is being requested in accordance with 49 CFR Parts 40,382 and 391.
Past Employer’s Name:
Past Employer’s Address:   Street Address   Address Line 2   City   State   Zip
Past Employer’s Phone#:   Phone Number   Past Employer’s Fax#Fax Number
Applicant’s Signature   Signature
COMPLETED BY PREVIOUS EMPLOYER
Driver's Name: First Name Last Name SSN: Number
1. Employed From Date to Date
2. Position(s) Held: Local Regional Over-the-Road
3. Did this driver operate commercial motor vehicles greater than 26,000GVWR?
4. Type of equipment operated: Dry Van, Flatbed, Reefer, Other
5. Reason for Leaving: Resignation Lay-Off Terminated MilitaryDuty if Terminated, why
6. Eligible for rehire? YES NO Upon Review
7. Was His/her general conduct satisfactory?
8. History of past driving record for past three year if applicable Motor Vehicle Accident/Equipment Damage/Incident Inquiry :
ACCIDENT:YES   NO
Under Departm ent of Transportation testing requirements:

Has this driver ever had a breath alcohol test within the past 3 years a result of 0.04 or higher alcohol concentration?   Yes   No

Has this driver ever had a positive test in the past 3 years?   Yes   No

Has this driver refused a controlled substance test and/or alcohol test within the past 3 years?   Yes   No

Hast this driver violated any other DOT drug/alcohol regulation?   Yes   No
To your knowledge has this driver violated any DOT drug and alcohol regulations at a previous employer?   Yes   No

PLEASE COMPLETE AND SIGN THIS FORM
First Name   Last Name  , Title
Signature   , Date
Disclosure regarding background reports from the PSP Online Service
In connection with your application for employment with Capital Transportation, LLC. (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Capital Transportation, LLC. (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information 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 to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved 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 I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, 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 and Authorization, 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
Name*

First NameLast Name
Date*

MonthDayYear
Date
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49 C.F.R. 383.5.
General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse
I, First Name*   Last Name*   , hereby provide consent to Capital Transportation, LLC to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I’m consenting to multiple limited queries that will be conducted once a year.

I understand that if the limited query conducted by Capital Transportation, LLC indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Capital Transportation, LLC without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for Capital Transportation, LLC to conduct a limited query of the Clearinghouse, Capital Transportation, LLC must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by
FMCSA’s drug and alcohol program regulations

Signature*   Date*
AUTHORIZATION
By signing I agree I have read the above statements *
Should be Empty:

General Information

License Information

EMPLOYMENT HISTORY

Additional Information

Emergency contact information

Fair Credit Reporting Act-Disclosure Notice and Authorization Form

Motor Vehicle Record Request Form

PAST EMPLOYMENT SAFETY HISTORY REQUEST

Disclosure regarding background reports from the PSP Online Service

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

AUTHORIZATION