Driver-Application for Porky Joerling Trucking Inc

Date

Last Name

First Name

Middle Name

Phone:

Street

City

State

Zip Code

Position Applying For:

Type a question

TemporaryPart TimeFull Time

Who Referred You:

Rate of Pay Expected?

If yes, please explain below. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.

Have you ever been convicted of a felony? If yes, please explain below.

DRIVER EXPERIENCE AND QUALIFICATIONS

The Federal Motor Carrier Safety Regulations (49CFR391.21 (b) (2) requires that driver applicants state their date of birth and SS #.

month/day/year

Social Security Number

The Federal Motor Carrier Safety Regulations (49CFR391 Subpart E) requires that all driver applicants pass certain physical tests before they are hired to drive a motor vehicle.

Date of last Department of Transportation prescribed examination

Date

Can you provide a copy

Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, leg, hand or arm? Yes

YesNo

ALCOHOL AND CONTROLLED SUBSTANCE STATEMENT

The Federal Motor Carrier Safety Regulations 49CFR40.25(j) requires all persons with applying for a driving position requiring a commercial drivers license to answer the following questions:

1) Within the last two years, have you ever tested positive, or refused to test, on any pre employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work?

YesNo

2) Within the last two years, have you ever tested positive, or refused to test, on any type of drug or alcohol test administered by an employer for which you preformed safety-sensitive transportation work?

YesNo

3) If you answered yes to either 1 or 2 above, can you provide and/or obtain proof that you have successfully completed the DOT return-to-duty requirements?

YesNo

Applicants Signature

Date

Driver Licenses held in past 3 years must be shown

State

License Number

Type

Expiration Date

State

License Number

Type

Expiration Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

YesNo

B. Has any license, permit or privilege ever been suspended or revoked?

YesNo

C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes If you answered "Yes" to A, B, or C, attach a statement giving details.

YesNo

List states operated in during the last five years

List special courses or training that will help you as a driver:

List safe driving awards held and who awards were presented by

Current Employer

Supervisor's Name

Address

Supervisor's Name: Phone

Position Held

From

To

Salary

Reason For Leaving:

Previous Employer

Supervisor's Name

Address

Phone Number:

Position Held

From

To

Salary

Reason for leaving

Previous Employer

Supervisor's Name

Address

Phone

Position Held

From

To

Salary

Reason For Leaving

I certify that I have read and understand all of this employment application. It is agreed and understood that the employer or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and other persons named herein from all liability for any damages on account of his furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks that are pertinent to the job.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, personal reputation, personal characteristics and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of the employer.

This certifies that I completed this application and that all entries on it and information in it are true and complete to the best my knowledge.

Date

Signature

Applicant Information

Current Address

Employment Record

APPLICANT MUST READ AND SIGN