DRIVER APPLICATION

DRIVER APPLICATION
Company DriverOwner/OperatorIn-home Contractor
In compliance with Federal and State Equal Employment Opportunity laws, qualified applicants are considered for all positions without regard to race, color religion, sex, national origin, age, marital status, or non-job-related disability.
Date of Application:

MonthDayYear
Date
Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Social Security #
Drivers License #:
State:
Home Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Current Address:

Street Address

Street Address Line 2

CityState

Zip Code
How Long at Current Address?
(If less than 5 years, please list previous address)
Previous Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-Mail Address:
Are you currently employed?
If not, how long since leaving employment?
Why?
Who referred you?
Rate of pay expected?
Do you have the legal right to work in the United States?
Have you ever worked for this company before?
Dates: From:

MonthDayYear
Date
To:

MonthDayYear
Date
Position:
If so, reason for leaving:
Is there any reason you might be unable to perform the functions of the job for which you have applied? If yes, please explain:

Education
Highest Grade Completed:

High School:College:
Other:
(Please include all driving schools):
Last School Attended:

(Name)(City)
Graduation Date

Driving Experience (If NONE, write NONE)

Type

	Type of Equipment (Van, tanker, reefer, flat, etc.)	Dates (From / To)	Appx. Number Of Miles
Straight Truck
Tractor & Semi-Trailer
Tractor & Doubles
Motor Coach– School Bus
Other

List all states operated in for the last 5 years:
Did you attend truck driving school and/ or receive initial training by a carrier?
Please list carrier:
Did you receive any Safe Driving awards?
Please list:
Disclosures (Please initial the right column on the line next to each disclosure)
Multiple Employers
I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity
Initial here
Check of Driving Record
The Applicant is hereby informed that the MVR will be obtained for the purpose of investigation as required by Sections 391.23 and 391.25 of the FMCSRs. The furnished is released from any and all liability, which may result from furnishing such information.
Initial here
Fair Credit Reporting Act Disclosure Statement
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 I, 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 FMCSRs.
Initial here
TO BE READ AND SIGNED BY THE APPLICANT
This certifies that I have completed this application, 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 investigation and inquire of my personal, employment, medical history, and/ or motor vehicle reports containing driving history and other related matters as may be necessary in 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 inquire 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.
Signature of Applicant

Clear
Date

MonthDayYear
Date

PREVIOUS EMPLOYMENT VERIFICATION REQUEST
The below named individual has made application to Rapid Response, Inc. for a position as Truck Driver and states that he/ she was employed by you as:
Printed name:
SS#
DOT DRUG AND ALCOHOL RELEASE

In accordance with DOT Regulation 49 CFR Part 391.23, I authorize the release of information from my DOT regulated drug and alcohol testing records by the carriers (company/school) listed above to HireRight (formerly USIS) for the sole purpose of transmitting such records to Rapid Response, Inc. I authorize release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation(s); and (vi) documents, if any, of completion of a return-to-duty process following a rule violation.

I hereby authorize, without liability, any person or organization whose name I have given as a reference, or by whom I have been previously employed or contracted with, to furnish Rapid Response, Inc. any information they may have concerning my safety performance, all accidents, including those defined in 390.5 of FMCSR, all drug and alcohol testing violations (in compliance with 49 C.F.R. Sections 382 sub part B, 382.405, 382.413, 391.89, 392.4, 392.5, 40.37 and 40.81 (1), refusals or completed rehabilitations, character, habits, ability, financial responsibility, job performance or other work-related characteristics, reason for leaving employment/lease and all information concerning my employment/lease. I hereby release all such persons and organizations from any claims for damages of any kind which may occur to be my reason of furnishing such information.

The information that I have authorized HireRight to review involves tests required by DOT. If any carrier (company/school) listed above furnishes HireRight with information concerning items (i) through (vi) above, I also authorize that carrier (company/school) to release and furnish the dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the three year period and the name and phone number of any substance abuse professional who evaluated me during the past three years.

I hereby authorize you to release the aforementioned information, including Drug & Alcohol testing, to Rapid Response, Inc. for the purpose of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing suchinformation.
Applicants Signature:

Clear
Date

MonthDayYear
Date
Applicant Printed Name:
SSN:
General Consent for Queries of The Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse
I, , hereby provide consent to Rapid Response to
conduct a Pre-Employment Full Query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse as required under section 382.701(a). I further understand that if I refuse to provide consent for Rapid Response to conduct a Full Query of the Clearinghouse, Rapid Response must prohibit me from performing safety sensitive functions, including driving a Commercial Motor Vehicle, as required under the FMCSR section 382.703(d).

I, , hereby provide consent to Rapid Response to
conduct as many Limited Queries as they see fit throughout the duration of my employment. If any information about me exists in the Clearinghouse, I understand that Rapid Response must conduct a Full Query as stated in section 382.701(3). I further understand that if I refuse to give my consent Rapid Response must not allow me to perform any safety sensitive functions, including driving a Commercial Motor Vehicle
Driver Signature

Clear
Date

MonthDayYear
Date
Driver’s License

***Please provide a copy of your driver’s license with this signed form.
Cancelof
Should be Empty:

	Date	Nature of Accident (Head-On, Rear-End, Upset, etc.)	Injuries or Fatalities?	Est. Cost over $1,000
1
2
3
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5

	Date	Location	Charge	Penalty
1
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5

DRIVER APPLICATION

Employment History

Additional Employment History

Education

Experience and Qualifications – Drivers

Driving Experience (If NONE, write NONE)

PREVIOUS EMPLOYMENT VERIFICATION REQUEST

	State	License No.	Type	Expiration
1
2
3
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