APPLICATION PACKET - Alternative Fuels Application

CMV DRIVER'S EMPLOYMENT APPLICATION

(per 49 CFR 391.21)
Please Fill Out the ENTIRE Form
Date of Application*

MonthDayYear
Date
PLEASE READ COMPLETELY

The information requested on this form is required by federal law (49 CFR) to be provided by any driver applying for a commercial driver position as defined in 49 CFR 390.5. Failure to complete required areas can place both the applicant and carrier in violation of federal law. Information provided will be verified by carrier as required under various parts of 49 CFR, including Part 382 and Part 391. If unsure of question or require help with competing form please ask carrier representative. PLEASE PRINT CLEARLY AND SIGN YOUR FULL LEGAL NAME AT THE END WHERE REQUIRED.FALSE STATEMENTS MAY RESULT IN REFUSAL TO HIRE OR IMMEDIATE TERMINATION.
First Name*
Middle Name
Last Name*
Social Security Number*
Date of Birth*

MonthDayYear
Date
Document Presented to Verify Age*
Email*
example@example.com
Terminal Applying For*
Current Address (Street)*
City*
State*
Zip*
How Long? (year/month)*
Previous Address (If Less Than 3 Years) - Street
Previous Address (If Less Than 3 Years) - City
Previous Address (If Less Than 3 Years) - State
Previous Address (If Less Than 3 Years) - Zip
How Long? (year/month)*
Previous Address (If Less Than 3 Years) - Street
Previous Address (If Less Than 3 Years) - City
Previous Address (If Less Than 3 Years) - State
Previous Address (If Less Than 3 Years) - Zip
How Long? (year/month)
Previous Address (If Less Than 3 Years) - Street
Previous Address (If Less Than 3 Years) - City
Previous Address (If Less Than 3 Years) - State
Previous Address (If Less Than 3 Years) - Zip
How Long? (year/month)
Phone Number*
Please enter a valid phone number.
Is there any reason you might be unable to perform the functions of the job for which you have applied? Are you applying for ADA consideration?*

YesNo
If you answered yes to to any reason you might be unable to perform the functions of the job for which you have applied? Are you applying for ADA consideration, please explain if you wish (if not, please enter N/A)*
Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.
This form is made available with the understanding that NATC, Inc. is not engaged in rendering legal, accounting, or other professional services. NATC, Inc. assumes no responsibility for the use of this form, or any decision made by an employer which may violate local, state, or federal law.

EMPLOYMENT HISTORY

All applicants must provide the following information for any previous employer during the preceding 3 years. Complete all areas below. Applicants shall also provide an additional 7 years of information for those employers for whom the applicant has operated a commercial motor vehicle (CMV). (NOTE: List employers in reverse order starting with the most recent. Use additional sheet if necessary.)
Current Employer
Current Employer Company Name*
Current Employer Address*
Current Employer Address (City)*
Current Employer Address (State)*
Current Employer Address (Zip)*
Current Employer Contact Person*
Current Employer Contact Phone Number*
Current Employer Dates Employed (Month/Year) From*
Current Employer Dates Employed (Month/Year) To*
Current Employer Position Held*
Current Employer Salary/Wage*
Current Employer Reason For Leaving*
WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED?*

YesNo
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?*

YesNo

Previous Employer

If the previous employment, you already listed, gives a combined history of the last 10 years click next until you get to the accident record page.
Previous Employer Company Name
Previous Employer Address
Previous Employer Address (City)
Previous Employer Address (State)
Previous Employer Address (Zip)
Previous Employer Contact Person
Previous Employer Contact Phone Number
Previous Employer Dates Employed (Month/Year) From
Previous Employer Dates Employed (Month/Year) To
Previous Employer Position Held
Previous Employer Salary/Wage
Previous Employer Reason For Leaving
WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED?

YesNo
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

YesNo

Previous Employer

If the previous employment, you already listed, gives a combined history of the last 10 years click next until you get to the accident record page.
Previous Employer Company Name
Previous Employer Address
Previous Employer Address (City)
Previous Employer Address (State)
Previous Employer Address (Zip)
Previous Employer Contact Person
Previous Employer Contact Phone Number
Previous Employer Dates Employed (Month/Year) From
Previous Employer Dates Employed (Month/Year) To
Previous Employer Position Held
Previous Employer Salary/Wage
Previous Employer Reason For Leaving
WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED?

YesNo
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

YesNo

Previous Employer

If the previous employment, you already listed, gives a combined history of the last 10 years click next until you get to the accident record page.
Previous Employer Company Name
Previous Employer Address
Previous Employer Address (City)
Previous Employer Address (State)
Previous Employer Address (Zip)
Previous Employer Contact Person
Previous Employer Contact Phone Number
Previous Employer Dates Employed (Month/Year) From
Previous Employer Dates Employed (Month/Year) To
Previous Employer Position Held
Previous Employer Salary/Wage
Previous Employer Reason For Leaving
WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED?

YesNo
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

YesNo

Previous Employer

If the previous employment, you already listed, gives a combined history of the last 10 years click next until you get to the accident record page.
Previous Employer Company Name
Previous Employer Address
Previous Employer Address (City)
Previous Employer Address (State)
Previous Employer Address (Zip)
Previous Employer Contact Person
Previous Employer Contact Phone Number
Previous Employer Dates Employed (Month/Year) From
Previous Employer Dates Employed (Month/Year) To
Previous Employer Position Held
Previous Employer Salary/Wage
Previous Employer Reason For Leaving
WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED?

YesNo
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

YesNo

Accident Record

PROVIDE THE FOLLOWING INFORMATION FOR ANY ACCIDENT YOU WERE INVOLVED IN DURING THE PRECEDING 3 YEARS (IF NONE, leave "Last Accident" and "Next Previous" fields blank)
Last Accident (Month/Year)
Nature of Accident*
If Other Type of Accident was selected please explain
FATALITIES (yes or no)*
INJURIES (yes or no)*
HAZARDOUS MATERIAL SPILL (yes or no)*
Next Previous (Month/Year)
Nature of Accident*
If Other Type of Accident was selected please explain
FATALITIES (yes or no)*
INJURIES (yes or no)*
HAZARDOUS MATERIAL SPILL (yes or no)*
Next Previous (Month/Year)
Nature of Accident*
If Other Type of Accident was selected please explain
FATALITIES (yes or no)*
INJURIES (yes or no)*
HAZARDOUS MATERIAL SPILL (yes or no)*

TRAFFIC CONVICTIONS

PROVIDE THE FOLLOWING INFORMATION FOR ALL MOTOR VEHICLE VIOLATIONS FOR WHICH YOU WERE CONVICTED OR PLED GUILTY TO DURING THE PRECEDING 3 YEARS (DO NOT INCLUDE PARKING TICKETS) - (IF NONE, leave "Location" fields blank)
Location
Date*
Charge*
Penalty*
Location
Date*
Charge*
Penalty*
Location
Date*
Charge*
Penalty*

EXPERIENCE AND QUALIFICATIONS - DRIVER (ATTACH SHEET IF MORE SPACE IS NEEDED)

LIST ALL DRIVER LICENSES OR PERMITS HELD IN THE PAST 3 YEARS
DRIVER LICENSES
State*
License Number*
Type*
Expiration Date*

MonthDayYear
Date
Additional Driver's Licenses?*
State*
License Number*
Type*
Expiration Date*

MonthDayYear
Date
State*
License Number*
Type*
Expiration Date*

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

YesNo
Has any license, permit or privilege ever been suspended or revoked?*

YesNo
IF THE ANSWER TO EITHER QUESTION IS YES, GIVE DETAILS*

DECLARATION OF EMPLOYMENT STATUS

Under Federal Motor Carrier Safety Regulations (FMCSR Section 391.23), we are required to verify the employment background of all prospective drivers for the preceding three (3) years. This form is designed to enable you to account for any period of more than 30 days when you were not employed, which cannot be verified by any other means. In the section below, please fill in the dates and describe your activities during this time.
Name*
Social Security No.*
From - Month/Year
To - Month/Year
From - Month/Year
To - Month/Year
During the period specified, I was engaged in the following:*
I also confirm that during the above-listed period of time (check all that apply):

I was not employed on a full-time or regular part-time basisI was self-employedI did not collect unemployment during this periodI was not convicted of a crime involving a motor carrier or any aspect of the motorcarrier industryI was not involved in a motor vehicle accident of any kind
Signature*

Clear
Date*

MonthDayYear
Date
NOTE: Applicants should complete as many Declarations as necessary to fill in any gaps in employment history of more than 30 days so that a complete 10 years of employment is provided when required.

MANDATORY DRIVERS SAFETY PERFORMANCE HISTORY(REQUEST for PREVIOUS EMPLOYER INFORMATION)

REPLY REQUIRED by FEDERAL LAW (49 CFR 391.23)
Name of Applicant:*
Social Security No.:*
D.O.B.:*
CDL #:*
State:*
I authorize release of the information contained on this form as required under 49 CFR 40.331, 382.413, 391.23 and other applicable requirements. I acknowledge, that I have the right to due process as identified in 49CFR 39.23 to correct information submitted under this authorization.
Driver's Signature*

Clear
Date*

MonthDayYear
Date

STATE MOTOR VEHICLE LICENSING AGENCY

RECORD CHECK RELEASE FORM
I (enter your name in the field below) am fully aware that Prospect Transportation, Inc. and/or its agents, will perform a state licensing agency motor vehicle background check on me from a professional service for employment purposes. The information below has been provided by my own accord per the requirements of a motor vehicle check under 49 CFR Part 391.*
Full Name
Full Name:*
Home Address:*
City, State and Zip:*
Social Security Number:*
Date of Birth*

MonthDayYear
Date
Driver’s License Number:*
State of Issue:*
Name as Shown on Driver’s License:*
Your Signature:*

Clear

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with PROSPECT TRANSPORTATION, INC. (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report.

State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize PROSPECT TRANSPORTATION, INC. (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Date*

MonthDayYear
Date
Signature*

Clear
Name*
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier SafetyAdministration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSPreport. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. Thelanguage must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be includedwith other consent forms or any other language.LAST UPDATED 12/22/2015

General Consent for Limited QueriesOf the Federal Motor Carrier Safety Administration (FMCAS)

Drug and Alcohol Clearinghouse
I,(enter name below), hereby provide consent to PROSPECT TRANSPORTATION, INC./ ALTERNATIVE FUELS TRANSPORTATION, INC/ PROSPECT TRANSPORTATION OF NEW ENGLAND, INC./ PROSPECTTRANSPORTATION OF FLORIDA, INC to conduct limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) for the duration of my employment to determine whether drug or alcohol violation information about me exists in the clearing house. I understand that if the limited query conducted indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent to conduct a limited query of the Clearinghouse, this company must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’S drug and alcohol program regulations.*
Full Name
Please Print Your First and Last name, CDL Number, State Issued and Date of Birth.
First Name *
Last Name*
CDL/Driver’s License Number*
State Issued*
Date of Birth*

MonthDayYear
Date
Employee Signature*

Clear
Date*
Front of License

Cancelof
Back of License

Cancelof
Front of TWIC Card

Cancelof
Back of TWIC Card

Cancelof
PSP Report

Cancelof
Should be Empty:

CMV DRIVER'S EMPLOYMENT APPLICATION

Please Fill Out the ENTIRE Form

PLEASE READ COMPLETELY

This form is made available with the understanding that NATC, Inc. is not engaged in rendering legal, accounting, or other professional services. NATC, Inc. assumes no responsibility for the use of this form, or any decision made by an employer which may violate local, state, or federal law.

EMPLOYMENT HISTORY

Current Employer

Previous Employer

Previous Employer

Previous Employer

Previous Employer

Accident Record

TRAFFIC CONVICTIONS

EXPERIENCE AND QUALIFICATIONS - DRIVER (ATTACH SHEET IF MORE SPACE IS NEEDED)

DRIVER LICENSES

DRIVING EXPERIENCE - Check Yes or No

CLASS OF EQUIPMENT

DRUG AND ALCOHOL INFORMATION

CHECK ALL THAT APPLY:

DECLARATION OF EMPLOYMENT STATUS

NOTE: Applicants should complete as many Declarations as necessary to fill in any gaps in employment history of more than 30 days so that a complete 10 years of employment is provided when required.

MANDATORY DRIVERS SAFETY PERFORMANCE HISTORY(REQUEST for PREVIOUS EMPLOYER INFORMATION)

I authorize release of the information contained on this form as required under 49 CFR 40.331, 382.413, 391.23 and other applicable requirements. I acknowledge, that I have the right to due process as identified in 49CFR 39.23 to correct information submitted under this authorization.

STATE MOTOR VEHICLE LICENSING AGENCY

General Consent for Limited QueriesOf the Federal Motor Carrier Safety Administration (FMCAS)

Please Print Your First and Last name, CDL Number, State Issued and Date of Birth.