Southwest American Trucking Contract Driver Application 2

1

Name* This field is required.

First Name

Middle Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Email* This field is required.

example@example.com

Confirm Email

4

Date of Birth* This field is required.MM-DD-YYYY

5

Social Security Number* This field is required.

6

Available Start Date* This field is required.

Date

7

Do you have the legal right to work in the United States?* This field is required.

YESNO

8

Current Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

9

Number of years at Current Address?* This field is required.

10

Previous Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

11

Number of years at Previous Address?* This field is required.

12

Current License* This field is required.

License Number

State

Expiration Date

Type/Class

Endorsements

13

Have you held a license in any other state?* This field is required.

YESNO

14

Previous License* This field is required.

License Number

State

Expiration Date

Type/Class

Endorsements

15

What years have you driven Tractor Trailer?* This field is required.

Ex. 2015-Present

16

Tractor Trailer - Approximate number of miles driven* This field is required.

17

Do you have any additional driving experience?Please include type of equipment and years driven.

18

Have you had any accidents within the last 5 years?* This field is required.

YESNO

19

List all Accidents within the last 5 years below. List the most recent first.

20

Did any of the above listed accidents include a chemical spill?

YESNO

21

Have you had any traffic violations in the past 5 years?* This field is required.

YESNO

22

List all Traffic Violations for the past 5 years.List the most recent first.

23

Have you ever been denied a license, permit or privilege to operate a motor vehicle?* This field is required.

YESNO

24

Has any license, permit or privilege ever been suspended or revoked?* This field is required.

YESNO

25

Current, most recent, Employer* This field is required.

Name of Employer

Employer's Address (street, city, state, zip)

Supervisor's Name

Supervisor's Phone Number

Supervisor's Email Address

Position Held

Date worked at employer (MM/YYYY to MM/YYYY)

26

While employed with your most recent employer, were you subject to the Federal Motor Carrier Safety Regulations?* This field is required.

YESNO

27

Was your job with your most recent employer designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?* This field is required.

YESNO

28

Second, most recent, Employer* This field is required.

Name of Employer

Employer's Address (street, city, state, zip)

Supervisor's Name

Supervisor's Phone Number

Supervisor's Email Address

Position Held

Date worked at employer (MM/YYYY to MM/YYYY)

29

While employed with your second most recent employer, were you subject to the Federal Motor Carrier Safety Regulations?* This field is required.

YESNO

30

Was your job with your second, most recent employer, designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?* This field is required.

YESNO

31

Third, most recent, Employer* This field is required.

Name of Employer

Employer's Address (street, city, state, zip)

Supervisor's Name

Supervisor's Phone Number

Supervisor's Email Address

Position Held

Date worked at employer (MM/YYYY to MM/YYYY)

32

While employed with your third, most recent employer, were you subject to the Federal Motor Carrier Safety Regulations?* This field is required.

YESNO

33

Was your job with your third, most recent employer, designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?* This field is required.

YESNO

34

Do you have any gaps of employment, greater than a month?* This field is required.

YESNO

35

Explain any gaps of employment of more than 1 month.

36

High School Education* This field is required.

Name of High School

Location of High School

Number of years completed

Year of graduation

37

College Education

College Name

College Location

Course of Study

Year of Graduation

Degree Earned

38

List any additional qualifications that you have and which you believe should be considered.

39

Emergency Contact 1* This field is required.

First Name

Last Name

40

Emergency Contact 1 Phone Number* This field is required.

Please enter a valid phone number.

41

Emergency Contact 1 Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

42

What is Emergency Contact 1 relationship to you?* This field is required.

43

Emergency Contact 2* This field is required.

First Name

Last Name

44

Emergency Contact 2 Phone Number* This field is required.

Please enter a valid phone number.

45

Emergency Contact 2 Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

46

What is Emergency Contact 2 relationship to you?* This field is required.

47

I authorize Southwest American Trucking LLC to make investigations, including contacting current and prior employers, into my personal, employment, financial, medical history, MVR record 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 and ongoing requirements per Federal and State law.* This field is required.

48

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 Southwest American Trucking LLC. * This field is required.

49

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 CFR 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 field is required.

50

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. * This field is required.