Agape Driver Application

Agape Logistics LLC

Driver Application
Name*

First NameMiddle NameLast Name
Birthdate*

MonthDayYear
BOD
Phone Number*
Please enter a valid phone number.Format: (000)-000-0000.
SSN*
Please enter a valid SSN or EINFormat: 000-00-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
How Long*
Previous Address (back 3yrs)*

Street Address

Street Address Line 2

CityState

Zip Code
How Long*

Employment History
Address

Street Address

Street Address Line 2

CityState

Zip Code
Address

Street Address

Street Address Line 2

CityState

Zip Code
MonthDayYear
MonthDayYear
MonthDayYear
MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000)-000-0000.
Phone Number
Please enter a valid phone number.Format: (000)-000-0000.

Upload CDL*
Upload Medical Card*
Upload Social Security*

Applicant: Read the following statement, then print your name and sign the Application Form
I understand that in order to qualify for this position as an interstate commercial driver I must submit the employment controlled substance test, and must test negative before an offer of employment can be processed and is in accordance with US DOT Federal Motor Carrier Safety Regulations Part 391.I authorize Agape Logistics LLC to make any such inquiries and investigations of my driving and past employment background, personal, financial and/or medical history, I hereby release state agencies, employers, schools, health care providers and/or any other person from all liability in connection to their responding to any and all inquiries from Agape Logisitcs LLC and the subsequent release information to verify the accuracy of this application. I understand that in the event of my employment by Agape Logistics any false or misstatements given in my application or interview(s) may result in my discharge. I also understand that I have to abide by all rules and regulations of Agape Logistics LLC. This certifies that this application was completed by me, and that all entries on it and information in it is complete to the best of my knowledge.
Name*

First NameLast Name
Signature*

Consent From Pre-Employment Urinalysis

To Be Read And Sign By The Applicant
I understand that as required by the Federal Motor Carrier Safety Regulations Title 49 United States Code of Federal Regulations Section 391,103, and company policy, all prospective drivers must submit to a controlled substances test.
A urine sample will be collected and tested for controlled substances.
I also understand that if test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle. The results of the drug test will be maintained by the Medical Review Officer or the company who will report whether the test results were negative or positive to the motor carrier. The results will not be released to any additional parties without my written authorization.

Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre- employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety sensitive transportation work covered by DOT agency, drug and alcohol testing rules during the past two years.
If the employee admits that he or she had a positive test or refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process, (see Sec. 40.25(b)(5) and (e))

I hereby agree to submit to a drug screen- urinalysis.
Name*

First NameLast Name
Signature*

Acknowledgment To Independent Contractors Accidental Occupational Insurance
Yes, I want to buy insurance. Please contact us for applicationNo, I don't want to buy insurance
I am aware that it is my responsibility to provide work compensation insurance for myself. I also hold harmless Agape Logistics LLC for work compensation benefits for myself.
Name*

First NameLast Name
Signature*
Should be Empty:

Agape Logistics LLC

Employment Information

Employment History

Applicant: Read the following statement, then print your name and sign the Application Form

Consent From Pre-Employment Urinalysis

Acknowledgment To Independent Contractors Accidental Occupational Insurance