CDL Driver - Job Application Form

CDL Driver - Job Application Form
UPLOAD RESUME

Cancelof
I AUTHORIZE YOU TO MAKE SUCH INVESTIGATIONS AND INQUIRIES OF MY PERSONAL EMPLOYMENT, FINANCIAL OR MEDICAL HISTORY, AND OTHER RELATED MATTERS AS MAY BE NECESSARY FOR ARRIVING AT AN EMPLOYMENT DECISION. (GENERALLY, INQUIRIES REGARDING MEDICAL HISTORY WILL BE MADE ONLY IF AND AFTER A CONDITIONAL OFFER OF EMPLOYMENT HAS BEEN EXTENDED). 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 UNDERSTAND, ALSO THAT I AM REQUIRED TO ABIDE BY ALL RULES AND REGULATIONS OF THE COMPANY.

"I UNDERSTAND THAT INFORMATION I PROVIDE REGARDING CURRENT AND/OR PREVIOUS 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(D) AND (E). 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
- 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"
Signature

Clear
Date*

MonthDayYear
Date

Name*

First NameMiddle NameLast Name
Social Security Number*
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Date of Hire

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Past 10 Years of Residency

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Past 10 Years of Residency

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ACCIDENT HISTORY (10) YEARS
IF NO ACCIDENTS IN THE PAST 5 YEARS CHECK HERE
Date

MonthDayYear
Date
NATURE OF ACCIDENT
NUMBER OF FATALITIES
NUMBER OF INJURIES
HAZARDOUS MATERIALS SPILL?

YESNO
Date

MonthDayYear
Date
NATURE OF ACCIDENT
NUMBER OF FATALITIES
NUMBER OF INJURIES
HAZARDOUS MATERIALS SPILL?

YESNO

TRAFFIC CONVICTIONS AND FORFEITURES (5 YEARS)
IF NO TRAFFIC CONVICTIONS IN THE PAST FIVE YEARS CHECK HERE
Date

MonthDayYear
Date
VIOLATION
OTHER THAN PARKING
STATE OF VIOLATION
PENALTY
Date

MonthDayYear
Date
VIOLATION
OTHER THAN PARKING
STATE OF VIOLATION
PENALTY

LICENSE INFORMATION

SECTION 383.21 FMCSR STATES (NO PERSON WHO OPERATES A COMMERCIAL MOTOR VEHICLE SHALL AT ANY TIME HAVE MORE THAN ONE DRIVER'S LICENSE). I CERTIFY THAT I DO NOT HAVE MORE THAN ONE MOTOR VEHICLE LICENSE, THE INFORMATION FOR WHICH IS LISTED BELOW.
STATE

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
LICENCE NUMBER
EXPIRATION DATE

MonthDayYear
Date
HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT, OR PRIVILEDGE TO OPERATE A MOTOR VEHICLE?

YESNO
HAS ANY LICENSE, PERMIT, OR PRIVILEDGE EVER BEEN SUSPENDED OR REVOKED?

YESNO
IF YES EXPLAIN

APPLICANT CERTIFICATION

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge
Signature

Clear
Driver's License Number
Date

MonthDayYear
Date

DRUG AND ALCOHOL STATEMENT
Name

First NameLast Name
As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part 40.25(j) to respond to the following questions.
1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer or contract carrier to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

YesNo
2. If you answered "Yes" to the above question, can you provide proof that you have successfully completed the DOT return-to-duty requirements?

YesNo
3. Do you give Zumba Transportation consent to share your CDL information with the DOT FMCSA Commercial Driver's Drug and Alcohol Clearinghouse database?

YesNo
My signature below certifies that the information provided is true and correct.
Signature

Clear
Date

MonthDayYear
Todays Date

RELEASE AND AUTHORIZATION
I HEREBY AUTHORIZE YOU TO RELEASE THE FOLLOWING INFORMATION FOR THE PURPOSE OF INVESTIGATION AS REQUIRED BY 49 CFR 391.23 OF FEDERAL MOTOR CARRIERS SAFETY REGULATIONS. INFORMATION REQUESTED MAY INCLUDE ALL EMPLOYMENT OR CONTACT INFORMATION CONCERNING MY PERFORMANCE, FITNESS, AND ABILITY. YOU ARE HEREBY RELEASED FROM ANY AND ALL LIABILITY THAT MAY RESULT FROM FURNISHING SUCH INFORMATION.

I ALSO HEREBY AUTHORIZE YOU TO RELEASE THE FOLLOWING INFORMATION FOR THE PURPOSE OF INVESTIGATION. I authorize Zumba Transportation and Logistics Corporation to contact my previous employer(s) or carrier(s) in accordance with the current US DOT rules and regulations as set forth in 49 CFR 382.413 in order to obtain the following information for the preceding two years:
1. An alcohol test with a result of 0.04 alcohol concentration or greater
2. A verified positive controlled substances test results: and
3. Refusals to be tested.
I fully understand the above and do hereby give my consent to obtain the information required by 49 CRF 382.413.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN
CDL Number
Signature

Clear
Date

MonthDayYear
Todays Date
ROADSIDE INSPECTIONS (Optional): Was the applicant involved in any negative roadside inspections in the last 12 months? If so, please list the dates and types of violations discovered.
1. Date

MonthDayYear
Date
1. Type of Violation(s)
2. Date

MonthDayYear
Date
2. Type of Violation(s)
3. Date

MonthDayYear
Date
3. Type of Violation(s)
ALCOHOL AND DRUG HISTORY
1. Has the above named driver had an alcohol test with a result of 0.04 alcohol concentration for greater?

YesNo
2. Has the above named driver verified positive for a controlled substance test result?

YesNo
3. Has the above named driver refused a required test for alcohol or drugs during the past 12 months?

YesNo
4. Has a previous employer reported a verified positive result for controlled substance or alcohol on the named driver?

YesNo
If the answer to any of the above is yes, please identify the Substance Abuse Professional that administered treatment as required by the U.S. Department of Transportation.
Or, check here if it is unknown if the driver received treatment.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Should be Empty:

CDL Driver - Job Application Form

Employment History

Employment History

Employment History

EXPERIENCE AND QUALIFICATIONS

ACCIDENT HISTORY (10) YEARS

TRAFFIC CONVICTIONS AND FORFEITURES (5 YEARS)

LICENSE INFORMATION

APPLICANT CERTIFICATION

COMMERCIAL DRIVER EMPLOYMENT HISTORY

DRUG AND ALCOHOL STATEMENT

RELEASE AND AUTHORIZATION