Job Application Birka Logistics Inc

Birka Logistics Inc

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LICENSES
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EDUCATION
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Date
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What did you study?
Graduation Date

FMCSR
Under FMCSR 391.15, are you currently disqualified from driving a commercial motor vehicle? [49 CFR 391.15] *
Has your license, permit or privilege to drive ever been suspended or revoked for any reason? [49 CFR 391.21(b)(9)] *
Please provide additional detail, including the dates of the suspension(s)/revocation(s):
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?[49 CFR 391.21(b)(9)] *
Within the past two years, have you tested positive, or refused to test, on a pre-employment drug or alcohol test by an employer to whom you applied, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules? [49 CFR 40.25(j)] *
In the past three(3) years, have you ever been convicted of any of the following offenses: [49 CFR 391.15]: >Driving a commercial motor vehicle with a blood alcohol concentration ("BAC") of .04 percent or more >Driving under the influence of alcohol, as prescribed by state law Refusal to undergo drug and alcohol testing as required by any jurisdiction for the enforcement of Federal Motor Carrier Safety Act regulations >Driving a commercial motor vehicle under the influence of any 21 C.F.R. 1308.11 Schedule I identified controlled substance, an amphetamine, a narcotic drug, a formulation of an amphetamine, or a derivative of a narcotic drug >Transportation, possession, or unlawful use of a 21 C.F.R. 1308.11 Schedule I identified controlled substance, amphetamines, narcotic drugs, formulations of an amphetamine, or derivatives of narcotic drugs while you were on duty driving for a motor carrier >Leaving the scene of an accident while operating a commercial motor vehicle >Or any other felony involving the use of a commercial motor vehicle *

VEHICLE ACCIDENT RECORD
Were you involved in any accidents/incidents with any vehicle in the last 5 years (even if not at fault)?*
Accident Details

FatalitiesInjuriesHazardous SpillNon-InjuryOther
Date of Accident / Incident

MonthDayYear
Date
Was the vehicle towed away?
City/State

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Were you in a commercial vehicle?
If yes, was this a Department of Transportation recordable accident?
Were you at fault?
Were you ticketed?
Description

TRAFFIC CONVICTIONS/ VIOLATIONS
Have you had any moving violations or traffic convictions in the past 3 years?*
Violation Date

MonthDayYear
Date
Charge / Description
Violation State/Province

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In Commercial Vehicle
Fined?
License Suspended?
License Revoked?
Perform Community Service?
Other Penalty?
Fine Amount (if any):
Comments:

Traffic Convictions \ Violations 2
Violation Date

MonthDayYear
Date
Charge / Description
Violation State/Province

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In Commercial Vehicle
Fined?
License Suspended?
License Revoked?
Perform Community Service?
Other Penalty?
Fine Amount (if any):
Comments:

Traffic Convictions \ Violations 3
Violation Date

MonthDayYear
Date
Charge / Description
Violation State/Province

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In Commercial Vehicle
Fined?
License Suspended?
License Revoked?
Perform Community Service?
Other Penalty?
Fine Amount (if any):
Comments:

Traffic Convictions \ Violations 4
Violation Date

MonthDayYear
Date
Charge / Description
Violation State/Province

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In Commercial Vehicle
Fined?
License Suspended?
License Revoked?
Perform Community Service?
Other Penalty?
Fine Amount (if any):

Federal FCRA Summary of Rights Acknowledgment
By checking this box, I (a) acknowledge that I have read and understand the federal FCRA Summary of Rights and have been given the opportunity to copy/print the Summary of Rights and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. *
PSP Disclosure and Authorization
By checking the box, I (a) acknowledge that I have read and understand the PSP Disclosure and Authorization and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. *
FCRA Disclosure
By checking the box, I (a) acknowledge that I have read and understand the above and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. *
FCRA Authorization
By checking the box, I (a) acknowledge that I have read and understand the above and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. *
Employment Verification Acknowledgment and Release (DOT Drug and Alcohol)
By checking the box, I (a) acknowledge that I have read and understand the above and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. *
Summary of Rights Under 15 U.S.C. Section 1681m(a)
By checking the box, I (a) acknowledge that I have read and understand the Summary of Rights Under 15 U.S.C. Section 1681m(a) and have been given the opportunity to copy/print the 1681m Summary of Rights and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.*
INVESTIGATIVE CONSUMER REPORT DISCLOSURE
By checking this box, I represent that I understand and agree to the above Investigative Consumer Report Disclosure. *

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Birka Logistics Inc

Company Questions

DRIVING EXPERIENCE

LICENSES

Employment/Unemployment

EDUCATION

FMCSR

VEHICLE ACCIDENT RECORD

TRAFFIC CONVICTIONS/ VIOLATIONS

Federal FCRA Summary of Rights Acknowledgment

PSP Disclosure and Authorization

FCRA Disclosure

FCRA Authorization

Employment Verification Acknowledgment and Release (DOT Drug and Alcohol)

Summary of Rights Under 15 U.S.C. Section 1681m(a)

INVESTIGATIVE CONSUMER REPORT DISCLOSURE

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