American Distribution Driver Application Form

American Distribution Driver Application Form
Please read the following agreements and statements. Your signature below acknowledges your understanding of these agreements and statements. This is NOT a contract of employment. You are an independent contractor performing certain duties for American Distribution Services, Inc.

I understand that my engagement at American Distribution Services, Inc. is "At Will" and may be terminated by me or American Distribution Services, Inc. at any time for any reason.

I must meet the following requirements before and during my engagement:
- Pass U.S. DOT Controlled Substance and Alcohol Testing
- Pass all FMCSA physical requirements and provide current medical card certification
- Maintain a valid CDL in the state of primary residence
- Free of any Drug and Alcohol-related violations in the past 5 years
- Must be signed up with FMCSA Clearinghouse and comply with rules and regulations
  - A query will be run prior to hire as well as once per year for our company to stay compliant
- No felony convictions in the past 5 years (all others are reviewable)
- No accidents resulting from:
  - Rear-end, lane change/sideswipe or rollover
  - Hit and run along with failure to report the accident
  - No serious traffic violations in the past 3 years including, but not limited to, excessive speed equal to or greater than 15 MPH above posted limit
  - Reckless or erratic driving
  - Any violations which occur while engaged with American Distribution Services, Inc. will be reviewed at time of said violation
- Must be able to drive/operate in all lower 48 US states
- Adhere to American Distribution Services, Inc. company policies and procedures
Driver Signature *

Clear

Personal Information
Name *

First Name Last Name
SSN *
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Birthdate *

Month Day Year
Date
Race *
Gender *
Marital Status *
Name of Spouse (if married)

First Name Last Name
In Case of Emergency - Please Notify
Contact Name

First Name Last Name
Relationship
Contact Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Contact Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name of Nearest Relative

First Name Last Name
Address of Nearest Relative

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number of Nearest Relative
Please enter a valid phone number.

Voluntary Medical Information: Please list any medical history or medications you feel we should be aware of.
Previous 3 Years Residency
Address 1

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address 2

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address 3

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address 4

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
License Information and Driving Experience

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
License Number *
Type *
Expiration Date *

Month Day Year
Date

Driving Experience

	Type of Equipment	Approx. Number of Miles (Total)	Dates
Straight Truck
Tractor & Semi-Trailer
Tractor: Two Trailers
Other

Accident Record (Past 3 years or more)

	Date	Nature of Accident	# of Fatalities	# of Injuries	Chemical Spills (Y/N)
Accident 1
Accident 2
Accident 3
Accident 4
Accident 5

Traffic Convictions and Forfeitures (Past 3 years - excluding parking violations)

	Date Convicted	Violation	State of Violation	Penalty
Conviction 1
Conviction 2
Conviction 3
Conviction 4
Conviction 5

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

Yes No
If yes, please explain. *
Has any license, permit, or privilege ever been suspended or revoked? *

Yes No
If yes, please explain. *

Education

	Name & Location	Course of Study	Years	Graduate? Y/N	Details
High School
College
Other

Other qualifications
Please list any other qualifications that you have that you believe should be considered.
Employment History

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards. You are required to list the complete mailing address, including street number, city, state, ZIP, and complete all other information.
Current (or Most Recent) Employer
Company Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Position Held
Dates
Reason for Leaving
Salary
Explain any gaps in employment.
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes No
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by the 49 CFR, part 40?

Yes No

Second Most Recent Employer
Company Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Position Held
Dates
Reason for Leaving
Salary
Explain any gaps in employment.
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes No
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by the 49 CFR, part 40?

Yes No

Third Most Recent Employer
Company Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Position Held
Dates
Reason for Leaving
Salary
Explain any gaps in employment.
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes No
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by the 49 CFR, part 40?

Yes No

Motor Vehicle Driver's Certification of Violations 49 CFR 391.27

I certify that the following is a true and complete list of traffic violations required to be listed for which I have been convicted or forfeited bond or collateral during the past 12 months.
Have you had violations in the past 12 months? *

Yes No

Violations in the past 12 months

	Date	Offense	Location	Type of Vehicle
Violation
Violation
Violation
Violation
Violation
Violation
Violation

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12months.
Driver Signature *

Clear
Date *

Month Day Year
Date

To Be Read and Signed by Applicant
I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CF 391.23. 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; and
- 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.
This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.
Applicant Signature *

Clear
Applicant Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty:

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American Distribution Driver Application Form

Personal Information

In Case of Emergency - Please Notify

Previous 3 Years Residency

License Information and Driving Experience

Employment History

Motor Vehicle Driver's Certification of Violations 49 CFR 391.27

To Be Read and Signed by Applicant