North Point Transport Driver Employment Application

Employment Application

PO Box 393, Killdeer, ND 58640
Applicant Information
Today's Date*

MonthDayYear
Date

Applicant Information
Name*

First NameMiddle NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Social Security Number*
Position Applied For
Date Available for Work

MonthDayYear
Date
Do you have the legal right to work in the United States?*

YesNo

Emergency Contact Information
Name

First NameLast Name
Relationship to Applicant
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship to Applicant
Phone Number
Please enter a valid phone number.

Residence History

Please provide a complete 3-year residence history. If you need more space, write the information on paper and add it as a photo using the "Take Photo" or "Browse Files" button at the bottom of this page.

Current Residence

Previous Residences
List Previous Residences (if current residence is less than 3 years old)

Add Photo or File if Needed
From Phone: If You Need More Space Please Clearly Write or Type Out the Information and Take a Photo Here
From Computer: If You Need More Space Upload a File Here

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License Information

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed via photo from your cell phone or file upload from your computer.

License Information
Current License Information
Current License*
From Phone: Use The Buttons Below To Take Pictures Of The Front And Back Of Your Current License
Front Of Current License
Back Of Current License
From Computer: Upload Pictures Of The Front And Back Of Your Current License Here

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Previous License Information (If Needed)
Previous License Information
List Previous Licenses (if current license is less than 3 years old)
Previously Held License
Previously Held License
From Phone: If You Need More Space Please Clearly Write or Type Out the Information and Take a Photo Here
From Computer: If You Need More Space Upload a File Here

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Med Card Information
Med Card Information
Med Card Expiration Date*

MonthDayYear
Date
From Phone: Use The Buttons Below To Take A Picture Of Your DOT Medical Card. Make sure the Med Card is clearly readable.
From Computer: Upload A Picture Of Your DOT Medical Card Here

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Driving History

Please provide a complete driving history, including your driving experience for as many years as are relevant, and accident and traffic violations for the last 3 years.

Driving Experience
List the Class and Type of Equipment You Have Experience Using and Approx # of Years for Each Including Any Endorsements
List the Class and Type of Equipment You Have Experience Using and Approx # of Years for Each, Including Any Endorsements
Add another section for each equipment Class and Type you have experience operating.

Accident Record For The Past 3 Years
List All Accidents You Have Been Involved In Over The Past 3 Years, Most Recent First. (Use the +Add Row button to include additional accidents.) If None Write N/A In One Of The Fields.*

Traffic Convictions and Forfeitures For The Past 3 Years (Other Than Parking Violations)
List Most Recent Violations First. (Use the +Add Row button to include additional violations.) If None Write N/A In One Of The Fields.*
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*

YesNo
If Yes, Explain:
Has any license, permit, or privilege ever been suspended or revoked?*

YesNo
If Yes, Explain:

Education and Qualifications

Education
High School
School Name and Location
Graduated

YesNo
Year Graduated
College
College Name and Location
Subject Studied
Number of Years Completed
Graduated

YesNo
Year Graduated
Driving or Trade School
School Name and Location
Subject Studied
Graduated

YesNo
Year Graduated

	Name & Location	Course of Study	Years Completed	Graduate (Y/N)
High School
College
Other

Other Qualifications
Please list any other qualifications that you have and which you believe should be considered.

Authorization
I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, 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.

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 NorthPoint Transport.
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 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.
Today's Date*

MonthDayYear
Date
Applicant Name*

First NameLast Name
Applicant Signature*

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