DRIVER`S APPLICATION Logo
  • Driver`s application

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  • TO BE READ AND SIGNED BY APPLICANT

    I authorize CROCK GROUND INC to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision.

    (Generally, inquiries regarding medical history will be made only if and alter a conditional offer of employment has been extended.)

    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 understand, also, that I am required to abide by all rules and regulations of the Company. I understand that information I provide regarding current and/or previous 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(d) and (e).

    I understand that I have the right to:

    • Review information provided by previous employers;

    • Have errors in the information corrected by previous employers and for those previous employers to re-send 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.

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  • EMERGENCY CONTACT INFO:

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  • EMPLOYMENT HISTORY


    Please, provide all required information COMPLETELY. The United States Department of Transportation requires that the driver applicants show all employment for past 3(three) years. Effective July 1, 1987, they must also show commercial driver employment for the 7(seven) years preceding this 3(three) year period. FMCSR 391.21(b)(10)(11).

    Please make sure there are no gaps longer than 30 days in your employment.

  • Employment period

  • Employment period

  • Employment period

  • Employment period

  • Employment period

  • Employment period

  • Employment period

  • Employment period

  • ACCIDENT RECORD FOR PAST 3 YEARS OR MORE

  • Last accident

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  • Second previous accident

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  • Third previous accident

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  • Fourth previous accident

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  • Fifth previous accident

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  • TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (other than parking violations)

  • First previous conviction

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  • Second previous conviction

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  • Thrid previous conviction

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  • Fourth previous conviction

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  • Fifth previous conviction

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  • DRIVING QUALIFICATIONS -List all drivers licenses (other than current) and permits held in past 3 years

  • First previous DL or permit

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  • Second previous DL or permit

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  • Third previous DL or permit

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  • DRIVING EXPERIENCE

  • I hereby certify that information in this application was completely provided by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

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  • CERTIFICATE OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS


    MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.


    The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.


    DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:


    1) POSSESS ONLY ONE LICENSE:


    You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license.
    If you have more than one license, keep the license from your state of residence and return the additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state.

  • The following license is the only one I will posses:

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  • 2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION:


    Sections 391 .15(b)(2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to:

    1) your employing motor carrier, and

    2) the state that issued your license (If the violation occurs in a state other than the one which issued your license).

    The notification to both the employer and state must be in writing.

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  • CONSENT FORM
    PRE - EMPLOYMENT URINALYSIS


    I understand that as required by the Federal Motor Carrier Safety Regulations Title 49 United States Code of Federal Regulations Section 391,103, and company policy, all prospective operators must submit to a controlled substances test.


    A urine sample will be collected and tested for controlled substances.


    I also understand that if test positive for use of controlled substances, I am not qualified to operate a commercial motor vehicle.


    The results of the drug test will be maintained by the Medical Review Officer or the company who will report whether the test results were negative or positive to the motor carrier. The results will not be released to any additional parties without my
    written authorization.

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  • CERTIFICATION OF RECEIPT AND UNDERSTANDING OF
    AND CONSENT TO COMPLY WITH THE COMPANY SUBSTANCE ABUSE PROGRAM


    The Company Is vitally concerned with those situations where the use of illegal drugs or the illegal use of legal drugs, and the misuse of alcohol can seriously interfere with an individuals health end job performance and The Company’s business operations, and is a hazard to the safety and welfare of other employees or the public at large.


    The Company has established a Substance Abuse Program for the purpose of maintaining a drug and alcohol free work place, in accordance with Federal Regulations and Company Policy.


    All existing covered persons and new applicants for covered positions must be drug and alcohol free in accordance with DOT Regulations and The Company Substance Abuse Program.


    I hereby authorize The Company to obtain my DOT drug and alcohol test results from my past employers to the previous two (2) years, in accordance with the Federal Regulations and understand that those test results will be kept strictly confidential.


    I understand The Company has designated a third party to act as its "Designated Agent" for the purpose of receiving and processing individual drug and alcohol test results administered to its employees and job applicants.


    I hereby authorize The Company’s "Designated Agent" to receive my drug and alcohol test results direct from The Company’s drug testing laboratories and alcohol testing facilities, and to process and report such test results to The Company in a
    confidential manner.

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  • FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT


    In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter J, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes.


    These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

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  • PREVIOUS PRE-EMPLOYMENT APPLICANT'S
    DRUG AND ALCOHOL TESTING STATEMENT


    Sec. 40.25(j) 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 sensitive 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 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 return-to-duty process. (see Sec. 40.25(b)(5) and (e)).

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  • REQUEST FOR CHECK OF DRIVING RECORDS

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  • In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), I hereby certify the following:
    1. The consumer (applicant) has authorized in writing the procurement of this report;
    2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment
    purposes;
    3. The information requested below will be used for a "permissible purpose" (i.e., information for employment purposes) and will be used for no
    other purpose;
    4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and
    5. Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report
    and the summary of consumer rights as provided with the report by the consumer reporting agency.
    I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records
    under the provisions of the Driver's Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Section 300002(a)).

  • OPERATORS STATEMENT OF ON-DUTY HOURS


    INSTRUCTIONS: Motor carriers when using an operator for the first time shall obtain from the operator a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form.

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  • I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at:

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  • DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK


    INSTRUCTIONS: When employed by a motor carrier, an operator must report to the carrier all on-duty time including lime working for other employers. The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor
    Carrier Safely Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contractor private motor carrier, also performing any compensated work for any non motor carrier entity.

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  • OPERATOR'S AKNOWLEDGEMENTS

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