DOT Application for Employment

DOT Application for Employment
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, gender, national origin, sexual orientation, age, marital status, or non-job related disability.
General Information
Date of Application

MonthDayYear
1st Available Start Date

MonthDayYear
Name

PrefixFirst NameMiddle InitialLast NameSuffix
Date of Birth

MonthDayYear
Email Address
example@example.com
Social Security Number
Please enter a valid social security number.Format: 000-00-0000.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Position Applied For
Who referred you?

Address Information
Please list your addresses of residency for the past 3 years.
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Years
Add another address?
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Years
Add another address?
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Years
Add another address?
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Years

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. Please list the complete mailing address, street number, city, state, and zip code.

Applicants to drive a commercial motor vehicle (which includes vehicles having a GVWR of 10,001 lbs, or more, vehicles designed to transport 9 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding) in interstate or intrastate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.

List employers in reverse order starting with the most recent.
Are you currently employed?
How long since leaving your previous employer?
Years
Is there any reason you might be unable to perform the functions for which you have applied?
You answered "Yes" to the previous question, please explain.

0/1000
Note: List employers in reverse order beginning with the most recent.
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Dates of Employment
Include Month and Year of Employment
Salary/Wage
Indicate hourly rate or annual salary
Name of Supervisor

First NameLast Name
Reason for leaving.

0/500
Was this position subject to Federal Motor Carrier Safety Regulations?
Was this position designated a "Safety-Sensitive Function" in any DOT mode subject to drug/alcohol requirements?
Add another employer?
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Dates of Employment
Include Month and Year of Employment
Salary/Wage
Indicate hourly rate or annual salary
Name of Supervisor

First NameLast Name
Reason for leaving.

0/500
Was this position subject to Federal Motor Carrier Safety Regulations?
Was this position designated a "Safety-Sensitive Function" in any DOT mode subject to drug/alcohol requirements?
Add another employer?
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Dates of Employment
Include Month and Year of Employment
Salary/Wage
Indicate hourly rate or annual salary
Name of Supervisor

First NameLast Name
Reason for leaving.

0/500
Was this position subject to Federal Motor Carrier Safety Regulations?
Was this position designated a "Safety-Sensitive Function" in any DOT mode subject to drug/alcohol requirements?
Add another employer?
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Dates of Employment
Include Month and Year of Employment
Salary/Wage
Indicate hourly rate or annual salary
Name of Supervisor

First NameLast Name
Reason for leaving.

0/500
Was this position subject to Federal Motor Carrier Safety Regulations?
Was this position designated a "Safety-Sensitive Function" in any DOT mode subject to drug/alcohol requirements?
Add another employer?
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Dates of Employment
Include Month and Year of Employment
Salary/Wage
Indicate hourly rate or annual salary
Name of Supervisor

First NameLast Name
Reason for leaving.

0/500
Was this position subject to Federal Motor Carrier Safety Regulations?
Was this position designated a "Safety-Sensitive Function" in any DOT mode subject to drug/alcohol requirements?
Add another employer?
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Dates of Employment
Include Month and Year of Employment
Salary/Wage
Indicate hourly rate or annual salary
Name of Supervisor

First NameLast Name
Reason for leaving.

0/500
Was this position subject to Federal Motor Carrier Safety Regulations?
Was this position designated a "Safety-Sensitive Function" in any DOT mode subject to drug/alcohol requirements?
For additional employers, please send resume to hiring@patsoffroad.com.

Education
Highest Level of Education Completed
Area of Study
Indicate course study for college level courses
Last School Attended
Indicate school name, city, and state

Driving History
Dates and Nature of Accident, Fatalities, and/or Injuries

(Head-On, Rear-End, Upset, Etc.)
Last Accident (If none, type "None")

Describe nature of accident, date, and any injuries which took place.0/250
Add another accident?
Next Previous Accident

Describe nature of accident, date, and any injuries which took place.0/250
Add another accident?
Next Previous Accident

Describe nature of accident, date, and any injuries which took place.0/250
Traffic Convictions and Forfeitures for the Past 3 Years

(Other than Parking Violations)
Traffic Violation (If none, type "None")

Describe location, date, charge, and penalty of traffic conviction and/or forfeiture.0/250
Add another violation?
Traffic Violation

Describe location, date, charge, and penalty of traffic conviction and/or forfeiture.0/250
Add another violation?
Traffic Violation

Describe location, date, charge, and penalty of traffic conviction and/or forfeiture.0/250
Experience and Qualifications-Driver
Driver's License Number
State of Issue
Type of License
Endorsements
If none, enter "None"
Date of Expiration

MonthDayYear
If expired, put today's date and mark box below as expired.
Is your license expired?
Front of Driver's License
Back of Driver's License
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Please explain, in detail, why you have been denied a license, permit, or privilege to operate a motor vehicle.

0/250
Has any license, permit, or privilege ever been suspended or revoked?
Please explain, in detail, why you a license, permit, or privilege to operate a motor vehicle was suspended or revoked.

0/250
Driving Experience

If none, leave blank

Rows	Type of Equipment	Years of Experience	Approximate Miles Driven	State(s) Driven
Van, Tanker, Flatbed
Straight Truck
Tractor Trailer
Doubles or Triples
Motor Coach/School Bus
Other

Special courses or training that will help you as a driver

0/250
Safe driving awards (Include company where earned)

0/250
Trucking, transportation, or other experience that may help you with Pat's Offroad

0/250
Courses or training other than those listed in this application

0/250
Special equipment or technical materials you are familiar with

0/250

To Be Read and Signed by Applicants

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.

I authorize you to make such investigations and inquire of my personal, employment, financial, criminal or medical history and other related matters as may be necessary at 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 personnel 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 interviews) may result in discharge. I also understand that I am required to abide by all rules and regulations of the company.
Signature
Today's Date

MonthDayYear

Request for Information from Previous Employer

Please enter information for companies which required you to use a license for the Federal Motor Carrier's Association. Only include companies from the past 3 years.
Company Name
Position
Dates of Employment
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Was this position subject to Federal Motor Carrier Safety Regulations?
Today's Date

MonthDayYear
Signature
Add Another Company?
Company Name
Position
Dates of Employment
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Was this position subject to Federal Motor Carrier Safety Regulations?
Today's Date

MonthDayYear
Signature
Add Another Company?
Company Name
Position
Dates of Employment
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Was this position subject to Federal Motor Carrier Safety Regulations?
Today's Date

MonthDayYear
Signature
Add Another Company?
Company Name
Position
Dates of Employment
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Was this position subject to Federal Motor Carrier Safety Regulations?
Today's Date

MonthDayYear
Signature

Release Disclosure and Authorization

In connection with my application for employment (Including contract for services) or at any time during my employment or contract, I agree to allow and hereby authorize Pat’s Offroad, Inc., to procure and compile a consumer report on me. This report may include information as to my character, reputation, mode of living, criminal history, military service, education, academic credentials, qualifications, employment history (Including job performance, experience, work habits and reason for termination, personal characteristics, credit and indebtedness, and motor vehicle driving record. This report may contain information from various public and private sources, including without limitation, corporations, courts and law enforcement agencies at the federal, state or local level, court records repositories, credit bureaus, departments of motor vehicles, past or present references, and any other source required to verify information that I have voluntarily supplied. I understand that I have the right to request additional disclosures as to the nature and scope of the investigative consumer report, Medical and workers compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws.

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 l, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections §382.413, §391.23, and §391.25 of the Federal Motor Carrier Safety Regulations.

By signing below, I agree to allow and hereby authorize, empower and release from all liability, without reservation, any party, person or agency including, without limitation, present and former employers, credit bureaus, educational Institution, corporations, court and law enforcement agencies at the federal, state or local level, courts record repositories, credit bureaus, departments of motor vehicles, educational institutions, the military and licensing or registration entities, contacted by Pat’s Offroad, Inc., to release information about me, including, without limitation, any of the Information described above. I agree that a fax, photocopy or electronic reproduction of this authorization is to be considered and accepted with the same authority as the original.
Legal Name

Legal First NameLegal Middle Name/InitialLegal Last Name
Other Names or Aliases Used (If none, type "None")
Signature
Today's Date

MonthDayYear
Date
These reports will be processed by: Pat's Offroad, Inc. 1925 Grand Ave Ste. 129 #70924 Billings, MT 59102 or (406) 213-8006.

Drug & Alcohol Program Consent Form

I hereby release the company, its officers, agents, employees, and attorneys from any and all liability that may in any way arise from, or in any way be connected with the company's drug & alcohol testing program, disciplinary program, or allowing me to continue to work with the company. I specifically waive any rights of action under any theory of law and the like including specifically but not limited to theories of negligent and/or intentional infliction of emotional distress, negligence, invasion of privacy, wrongful discharge, defamation, slander or any like or similar theory.

By my signature I acknowledge that I have read, understand, and agree to comply with the drug & alcohol testing program of Pat’s Offroad, Inc. As well as the U.S. Department of Transportation Regulations as contained in 49 CFR part 382.

I also understand that it is a condition of being considered for employment, and continued employment by the company that I agree to abide by the company policy. By my signature I consent to urine and/or breath testing for controlled substances and/or alcohol prior to and at any time during my employment when requested by my employer on a random or event triggered basis. I hereby specifically authorize the company to have all and immediate access to any and all of my urine and/or breath custody and control forms and the results thereof.

I understand and agree that I may not be under any degree of influence of alcohol or controlled substances at any time during my employ. Should any level of alcohol or controlled substance be detected in any of my breath or urine at any time while employed, the company shall have grounds for immediate termination of my employment. This authorization specifically covers any random or event triggered testing as may be required by the US. Department of Transportation Regulations or company policy.

Any positive test result or refusal to submit to any type of test shall constitute my automatic resignation from this company.
Signature
Today's Date

MonthDayYear
Date

Certificate of Compliance with Driver License Requirements

Motor Carrier Instructions:

The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 9 people, or transports hazardous materials that require placarding.

The requirement in Part 391applies to every driver who operates in intrastate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 9 people, or transports hazardous materials that require placarding.

Driver Instructions:

Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987.

They are as follows:
1. Possess Only One License: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license. If you have more than one license, keep the license from your state of residence and return the additional license to the states that issued them. Destroying a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by the state.
2. Notification of License Suspension, Revocation, or Cancellation: Section §391.15 (b)(2) and §383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the next business day of any revocation or suspension of your driver's license. In addition, Section §383.31 requires that any time you violate a state or local traffic law (other than parking, you must report it within 30 days to: 1) your employing motor carrier, and 2) the state that issued your license (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing.
The following license is the only one I will possess:
Driver's License Number
State of Issue
Date of Expiration

MonthDayYear
Driver Certification: I certify that I have read and understand the above requirements.
Signature
Today's Date

MonthDayYear
Date

Certificate of Compliance with Driver License Requirements

Motor Carrier Instructions:

Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than parking violations) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section §391.27). Drivers who have provided information required by Section §383.31 need not repeat that information of this form.

Driver Requirements:

Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation, which must be listed, he/she shall so certify (Section §391.27).

Certification of Violations-Completed by Driver
Name

First NameLast Name
Social Security Number
Please enter a valid social security number.Format: 000-00-0000.
Driver's License Number
State of Issue
Date of Expiration

MonthDayYear
If expired, put today's date and mark box below as expired.
Home Terminal
If you have had a violation, mark "Yes".
Violation 1
Date Operated

MonthDayYear
Date
Offense
Location
Type of Vehicle Operated
If you have had a 2nd violation, mark "Yes".
Violation 2
Date Operated

MonthDayYear
Date
Offense
Location
Type of Vehicle Operated
Signature
Today's Date

MonthDayYear
Date

Driver Statement of On-Duty Hours

(For Newly Hired Drivers)

Instructions:

Motor Carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for this carrier (Rule 395. (j)2) of the Federal Motor Carrier Safety Regulations).

Note:

Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form.

Enter the date and hours worked 7 days prior to your hire date.

Rows	1	2	3	4	5	6	7
Date
Hours Worked

Driver Certification for Other Compensated Work

Instructions:

When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in §395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, also performing any compensated work for any non-motor carrier entity.
Are you currently working for another employer?
At this time, do you intend to work for another employer while employed by this company?
I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employers) for compensation that I must inform this company immediately of such employment activity.I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employers) for compensation that I must inform this company immediately of such employment activity.
Signature
Today's Date

MonthDayYear
Date
Witness Name (Office Only)

First NameLast Name
Witness Signature (Office Only)
Date of Witness Signature (Office Only)

MonthDayYear
Date

Previous Pre-Employment Drug or Alcohol Test Disclosure

The following question is made necessary for employment with Pat's Offroad, Inc. by the Federal Motor Carriers Regulations Section §40.25.

Have you 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 covered by DOT agency drug and alcohol testing rules during the past 3 years?
I certify that the following is a true response to the question asked above, to the best of my knowledge:
You have answered yes to the above question. Please provide the name of the Substance Abuse Professional (SAP) that evaluated you below, along with the name of the agency that performed your return to duty test.
Substance Abuse Professional (SAP) Name:
Return to Duty Test:
Date(s) Attended:

Consent for Release of Information
Substance Abuse Professional (SAP) Name:
I hereby authorize you to release the following information to Pat's Offroad, Inc. for the purposes of investigation as required by Section §40.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information.
Signature
Today's Date

MonthDayYear
Date

Completed by Motor Carrier-Annual Review of Driving Record

Motor Carrier Instructions:

Review the Certification of Violations listed previously and other information described in Section §391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below.

I have hereby reviewed the driving record of the above named driver in accordance with Section §391.25 and find that he/she (Check one):

___________ Meets the minimum requirements for safe driving
___________ Is disqualified to drive a motor vehicle pursuant to Section §391.15
___________ Does not adequately meet satisfactory safe driving performance

____________________________________________________________________
Action taken with driver

_____________________________________________________
Name of Reviewing Authorized Representative

______________________________________________________
Title of Reviewing Authorized Representative

______________________________________________________
Signature of Authorized Representative

____________
Date
Should be Empty:

Pat's Offroad, Inc.	or	office@patsoffroad.com
1925 Grand Ave.		Subject Line: Letter of Release w/ Driver Name
Ste. 129 #70924
Billings, MT 59102