DRIVER'S APPLICATION FOR EMPLOYMENT

DRIVER'S APPLICATION FOR EMPLOYMENT
(Answer all questions)
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 NameMiddle NameLast Name
Social Security #:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
Phone
Please enter a valid phone number.
Address For Past Three Years?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How Long?
Address For Past Three Years?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How Long?
Do you have the legal right to work in the United States?
Date of Birth

MonthDayYear
Date
Can you provide proof of age?
Have you worked for this company before
Where?
Dates: From

MonthDayYear
Date
Dates: To

MonthDayYear
Date
Rate of Pay?
Position you held?
Reason for leaving?
Are you now employed?
If not, how long since last employment?
Who referred you?
Rate of pay expected:
Is there any reason you might know of that might inhibit you from performing the tasks related to the position for which you have applied for?
If yes, please explain based on what you understand those tasks are. If you need additional space for your response, please attach a supplemental document:
Notice to Applicant: Before you continue in filling out the remainder of this application, we must inform you that the information you have provided so far, and any and all information you are about to disclose, in accordance with 49 CFR Part 391.21 (b)(l 0) of the Federal Motor Carrier Safety Regulations (FMCSRs), may be used and your previous employers ''will be" contacted for the purpose of investigating your safety performance history as required by 39J.23(d) and 391.23(e) of the FMCSRs. If it has not already been provided for you, please ask for a written copy of your "due process rights" regarding any and all information obtained durin2 the processin2 of your history as specified in 391.23(1).

EXPERIENCE AND QUALIFICATIONS - OTHER

Accident record for past three (3) years or more. Attach sheet if more space is needed.

Dates

	Nature of Accident	Fatalities	Injuries
Last Accident
Next Previous

Traffic convictions for the past three (3) years (other than parking violations).

	Location	Date	Charge	Penalty
1
2

EDUCATION
Circle highest grade completed:
High School:
College:
Last School Attended:

Name

Street Address Line 2

CityState

Postal / Zip Code

EXPERIENCE AND QUALIFICATIONS - DRIVER

Driver Licenses

	State	License#	Type	Expiration Date
1
2
3

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
Have you ever been convicted of a felony?

YesNo
Explain:
(If the answer to any of the above is yes, attach statement giving details)

Driving Experience (if none, write NONE)

Class of Equipment

	Type of Equipment Date (Van, Tank, Flat, Etc.)	Date From	Date To	Approx. No. of Miles (Total)
Straight Truck
Tractor-Trailer
Doubles/Triples
Other

List states you operated in for the last five years:
Show special courses or training that will help you as a driver:
Which safe driving awards do you hold and from whom:
List special equipment or technical materials you can work with (other than those already shown):

TO BE READ AND SIGNED BY APPLICANT
Sec. 40.250): 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 sensiti ve 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 a 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 returnto-duty process. (see Sec. 40.25(b)(5) and (e)).
The prospective employee is required by Sec. 40.25(j) to respond to the following questions.
Have you ever tested positive or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

YesNo
If you answered yes, can you provide/obtain proof that you have successfully completed the DOT return-to-duty requirements?

YesNo
This certifies that I completed this application, and that all entries and in formation documented by me are true and complete to the best of my knowledge. By my signature heretofore, I acknowledge having been given by this carrier which has presented me with this application, a statement of my right to due process as outlined by all parts of 49 CFR Part 391.23 of the Federal Motor Carrier Safety Regulations effective October 29, 2004. Having made this acknowledgment, I therefore authorize you to make such previous employment and background investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary to arrive at a possible employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended). I understand that false or misleading information given in my application or interviews may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company.

I hereby understand and acknowledge that, un less otherwise defined by applicable law, any employment relationship with this organization is ofan ·'at will" nature, whi ch means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.
Date

MonthDayYear
Date
Applicant's Signature

Clear

MOTOR VEHlCLE RECORD RELEASE AND AUTHORIZATION FORM
The undersigned does hereby authorize the release and delivery of all motor vehicle driving records relating to the undersigned, including but not limited to personal information, to my prospective or present employer and its insurance company, whose names and addresses are as follows:
EMPLOYER

SERVICE ONE TRANSPORTATION, INC.
N5761 CTY RD M
PLYMOUTH, WI 53073
920-467-4793

INSURANCE COMPANY

GREAT WEST CASUALTY COMPANY
P. O. BOX 277
SOUTH SIOUX CITY, NE 68776
402-494-7324

This authorization shall continue in effect until revoked by the undersigned in a subsequent writing delivered to Service One Transportation, Inc. -
PRINTED NAME:
SS #:
SIGNATURE:

Clear
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DRIVERS LICENSE#:
STATE:

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 Servvice One Transp. ("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 FM CSA 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 ofFMCSA; that the FM CSA 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 FM CSA 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 (FM CSR) 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 Servvice One Transp. ("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 FM CSA 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. Ifl 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,

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
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant's consent. The language 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 included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of"employee" contained at 49 C.F.R. 383.5.

LAST UPDATED /12/22/2015

Service One Transpotation, Inc.
P.O.BOX 202
Plymouth, WI 53073
Should be Empty:

DRIVER'S APPLICATION FOR EMPLOYMENT

EMPLOYMENT HISTORY

EXPERIENCE AND QUALIFICATIONS - OTHER

EDUCATION

EXPERIENCE AND QUALIFICATIONS - DRIVER

TO BE READ AND SIGNED BY APPLICANT

MOTOR VEHlCLE RECORD RELEASE AND AUTHORIZATION FORM