CDL Delivery Drivers Application

Employment Application: DOT. This application is for CDL delivery drivers only. All other positions complete the Non-DOT Employment Application.
Job Application

Please complete the form below to apply for a position with us.
Full Name*

First NameMiddle NameLast Name
Today's Date*

MonthDayYear
Date
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Email Address*
Birth Date*

MonthDayYear
Do you have a valid drivers license?
Position Applied for:
**Please list the addresses at which you resided during the past 3 years preceding this application date: Address:
Are you authorized to work in the U.S.? *

Education
High School:
City & State of HS:
Years in HS:
Did you Graduate
College/University
City & State of University:
Years at University:
Did you Graduate
Degree:

Previous Employment:

Provide 7 years of Employment History, beginning with most recent
Company:*
Company Address:*
Job Title:*
Dates of Employment:*
Supervisor:*
Responsibilities:*
Reason for leaving:*
Was Job Designated as a Safety Sensitive Function in any DOT Regulated Mode Subject to Alcohol & Controlled Substances Testing Requirements as Required by 49 CFR part 40?*
Company:
Company Address:
Job Title:
Dates of Employment:
Supervisor:
Responsibilities:
Reason for leaving:
Was Job Designated as a Safety Sensitive Function in any DOT Regulated Mode Subject to Alcohol & Controlled Substances Testing Requirements as Required by 49 CFR part 40?
Company:
Company Address:
Job Title:
Dates of Employment:
Supervisor:
Responsibilities:
Reason for leaving:
Was Job Designated as a Safety Sensitive Function in any DOT Regulated Mode Subject to Alcohol & Controlled Substances Testing Requirements as Required by 49 CFR part 40?
Company:
Company Address:
Job Title:
Years:
Supervisor:
Responsibilities:
Reason for leaving:
Was Job Designated as a Safety Sensitive Function in any DOT Regulated Mode Subject to Alcohol & Controlled Substances Testing Requirements as Required by 49 CFR part 40?
Company:
Company Address:
Job Title:
Dates of Employment:
Supervisor:
Responsibilities:
Reason for leaving:
Was Job Designated as a Safety Sensitive Function in any DOT Regulated Mode Subject to Alcohol & Controlled Substances Testing Requirements as Required by 49 CFR part 40?
Accident & Traffic Convictions, past 3 years
Most Current: Include dates, type, injuries: Most current
Next Previous: Include dates, type, injuries
Next Previous: Include dates, type, injuries
Traffic Convictions; Include location, date, charge, fine
Driving Experience: include equipment (Class), Type (van, flat, tank, etc.) and dates driven
Driver’s License: include state, number, type, expiration date
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Has any personal license, permit or privilege to operate a motor vehicle been suspended or revoked?
If the answer to either of the above questions is yes, please attach or include additional details.
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Disclaimer and Signature
To the Applicant: Per the Federal Motor Carrier Safety Regulations Pocketbook, Section 391.23 (i): The prospective employer must expressly notify drivers with DOT regulated employment during the proceeding 3 years that he/she has the following rights regarding the investigative information provided above (and as described below following the asterisks), to Our Company: The right to review information provided by previous employers; the right to have errors in the information corrected by the previous employer and for that previous employer to resend the corrected information to Our Company; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.. Drivers who have previous DOT regulated employment history in the preceding 3 years, and wish to review previous employer-provided investigative information must submit a written request to Our Company, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. Our Company must provide this information to the applicant within 5 business days of receiving the written request. If Our Company has not yet received the requested information from the previous employer (s), then the 5-business day deadline will begin when Our Company receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within 30 days of Our Company making them available, Our Company may consider the driver to have waived his/her request to review the records.

***Section 391.23 (d): Our Company must investigate, at a minimum, the following information listed from all previous employers of the applicant that employed the driver to operate a CMV within the previous 3 years: general driver ID and employment verification information, accident information (as specified in 390.15 (b) (1), 390.5 and 390.15(b)(2)), whether within the previous 3 years the driver had violated the alcohol and controlled substances prohibitions under subpart B of 382 or 49 CFR part 40, whether the driver failed to undertake or complete a rehabilitation program prescribed by a substance abuse professional (SAP) pursuant to 382.605 or 49 CFR part 40, subpart 0. Further, for a driver who had successfully completed a SAP’s rehab referral, and remained employed by the referring employer, information on where the driver had the following testing violations subsequent to completion of a 382.605 or 49 CFR part 40, subpart 0 referral: alcohol tests with a result of 0.04 or higher alcohol concentration; verified positive drug tests, and refusals to be tested (including verified adulterated or substituted drug test results).

In consideration for employment with Our Company, if employed, I agree to conform to the rules, regulations, policies and procedures of Our Company at all times and understand that such compliance is a condition of employment. I understand that due to the nature of company business, attendance and punctuality are considered essential requirements of every job at our company and that poor attendance or tardiness will result in disciplinary action. I understand that if offered a position with Our Company, I may be required to submit to a pre-employment medical examination, drug screening and background check as a condition of employment (including driving record). I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed.

I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to Our Company and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information. This release of information covers my employment record in general. I agree that all former employers who provide such information are indemnified and released from liability arising from such disclosures. I also understand that if I do not sign this Application and Authorization for Release of Information, my application will be rejected. I understand that this application is considered current for three months. If I wish to be considered for employment after this period I must fill out and submit a new application.

BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS. I FURTHER CERTIFY THAT THIS APPLICATION WAS COMPLETED BY ME, AND THAT ALL ENTRIES ON IT AND INFORMATION IN IT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature

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WE ARE PROUD TO BE AN EQUAL OPPORTUNITY EMPLOYER. ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, DISABILITY, VETERAN STATUS OR ANY OTHER STATUS PROTECTED BY LAW.
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Job Application

Education

Previous Employment:

Accident & Traffic Convictions, past 3 years

Disclaimer and Signature