Site Safe Solutions, LLC provides equal employment opportunity to all persons regardless of race, age, color, religion, national origin, citizenship status, sex, gender, sexual orientation, gender identity and/or expression, genetic information, marital status, physical or mental disability, military status, veteran status, or any other characteristic protected by federal, state, or local law. In addition, Site Safe Solutions, LLC will provide reasonable accommodations for qualified individuals with disabilities.
DOT Employment Application
Position Applied For
Field Tech
DOT Driver
Supervisor
Other
Name
*
Social Security Number
*
Phone Number
*
Email
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you legally authorized to work in the United States?
*
Yes
No
Type of Employment Desired
*
Full Time
Part Time
Highest Level of Education Completed
*
High School
Trade
Associates
Bachelors
Have You Had Any Felony Convictions?
*
No
Yes, List Date and Details
Have You Had Any Misdemeanor Convictions?
*
No
Yes, List Date and Details
Have You Worked For This Company Before?
*
No
Yes, List Date and Details
Are You Presently Employed?
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Yes
No
If Yes, May We Contact Your Current Employer?
*
Yes
No
How were you referred to us?
*
Walk-In
Referral
Newspaper Ad
Facebook
Twitter
LinkedIn
Other
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Employment History
§391.21 (b)(10) List all periods of employment (full, part-time & seasonal), self-employment, unemployment and schooling during the past 10 years, beginning with the most recent time period. If unemployed or self-employed for over 30 days, provide means of verification (names, telephone numbers, documents, etc.) Any application received that is incomplete WILL NOT BE PRROCESSED.
1st Previous Employer
Contact Name and Number
Were you subject to the FMCSRs while employed with this company?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
2nd Previous Employer
Contact Name and Number
Were you subject to the FMCSRs while employed with this company?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
3rd Previous Employer
Contact Name and Number
Were you subject to the FMCSRs while employed with this company?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
4th Previous Employer
Contact Name and Number
Were you subject to the FMCSRs while employed with this company?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
5th Previous Employer
Contact Name and Number
Were you subject to the FMCSRs while employed with this company?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
6th Previous Employer
Contact Name and Number
Were you subject to the FMCSRs while employed with this company?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
7th Previous Employer
Contact Name and Number
Were you subject to the FMCSRs while employed with this company?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
8th Previous Employer
Contact Name and Number
Were you subject to the FMCSRs while employed with this company?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
9th Previous Employer
Contact Name and Number
Were you subject to the FMCSRs while employed with this company?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
10th Previous Employer
Contact Name and Number
Were you subject to the FMCSRs while employed with this company?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
Resume and Files
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Drivers Licenses
(List all Driver's Licenses Held in the Past Five Years)
Drivers License
Drivers License
Drivers License
Violations
List all violations of motor vehicle laws or ordinances (other than violations involving only parking) of which you were convicted or forfeited bond or collateral during the three consecutive years preceding the date of this application. (Three or more moving violations in the past three years may disqualify you from driving for the company.)
Date - Violation - Location - Penalty - Resolved, Y/N
*If violation is speeding, please note the actual speed and the speed limit, i.e. 65mph/55mph
Have you ever been convicted of Driving While Intoxicated, Driving Under the Influence, or any Alcohol or Drug related offense? (If yes list date of offense, type of vehicle and location)
*
No
Yes, List Date and Details
Have you ever been denied a license, permit or privileges to operate a motor vehicle?
*
No
Yes, Explain
Has any license, permit, or privilege ever been suspended or revoked?
*
No
Yes, Explain
Have you ever been disqualified from driving subject to CFR49 Section 391 of the Federal Motor Carrier Regulations?
*
No
Yes, Explain
Accidents
List below all motor vehicle accidents or incidents, preventable and non-preventable, in which you were involved in during the past three years
*Date - Location - Class of Vehicle - Property Damage - Personal Injuries - Fatalities - Preventable or Non-preventable
Additional Accident Details
*Date - Location - Class of Vehicle - Property Damage - Personal Injuries - Fatalities - Preventable or Non-preventable
Have you tested positive, or refused to test, on any pre-employment, random or post-accident drug or alcohol test administered by an employer or perspective employer during the past three years?
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No
Yes, List Date and Details
If yes, did you complete the return-to-duty process, as defined in CFR Part 40, Subpart O?
*
No
Yes, List Date and Details
Authorization for Information Release
Authorization for Release of Information concerning Alcohol and Controlled Substance test results as required by FMCSR 382.405 and 382.413. I am also aware that I maintain the right to review any I hereby authorize you to release any and all information concerning my employment records as required by FMCSR Section 391.23 and all information information provided by your company and to rebuttal any erroneous information.
Information Release
*
I hereby authorize anyone to furnish SITE SAFE any information as may be required on drug and alcohol testing, my personal record and/or character without recourse. I understand that if employed, any misrepresentation or false statement on this application revealed at a later date shall be considered sufficient cause for disqualification. I also understand this application in no way assures the applicant a position with SITE SAFE.I also understand that a consumer report, which may contain public record information, is being requested from HireRight services. This report may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, driving record, worker compensation claims, credit bankruptcy proceedings, criminal records from federal, state and other agencies which maintain such records, driving records requests from such state agencies, state provided driving records, claims involving me in the files of insurance. I further authorize SITE SAFE to supply the information listed above to include items of information as described in the federal motor carrier safety regulations to HireRight services and to other companies which subscribe to HireRight services or companies that request my work history listed above.The applicant agrees to furnish such additional information and complete such examinations as may be required to complete his or her file. It is agreed and understood that if hired, the employee may be placed on a trial basis during which time he or she may be discharged without recourse.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.
I certify 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.
*
Notice of Drug and Alcohol Testing
I understand that I must submit to Site Safe Solutions controlled substance and alcohol testing program and to provide biological samples to be tested. Controlled substances include, but are not limited to marijuana, cocaine, amphetamines, opiates, and phencyclidine. Site Safe Solutions may contract with a third party to obtain, analyze, and report on the samples provided. A positive controlled substance, and/or alcohol test, or refusal to test, will disqualify me from consideration for employment or will result in my termination if employed. Site Safe Solutions will also release this information to third parties upon receipt of a properly executed release document. A positive result or a refusal on a post-accident test may also result in denial of any Workers Compensation claims I make due to any injury sustained in an accident. My initials authorize Site Safe Solutions to withhold the cost of pre-employment tests if I terminate employment within 60 days of my hire date.
Notice of Drug and Alcohol Testing
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Agreement to Abide by All Rules
If employed, I agree to adhere to all rules, policies, guidelines, procedures, regulations, and statutes promulgated by or issuing from Site Safe Solutions OR local, state, or federal regulatory agencies. I understand that there is no expectation of privacy for any of my personal property on Site Safe Solutions premises, including vehicles. I consent to and agree that Site Safe Solutions may inspect my personal property, along with desks, lockers, toolkits, etc., to investigate possible violations of Site Safe Solutions rules, policies, guidelines, procedures or local, state, or federal regulations or statutes.
Agreement to Abide by All Rules
*
At-Will Employment
If employed, I agree to adhere to all rules, policies, guidelines, procedures, regulations, and statutes promulgated by or issuing from Site Safe Solutions OR local, state, or federal regulatory agencies. I understand that there is no expectation of privacy for any of my personal property on Site Safe Solutions premises, including vehicles. I consent to and agree that Site Safe Solutions may inspect my personal property, along with desks, lockers, toolkits, etc., to investigate possible violations of Site Safe Solutions rules, policies, guidelines, procedures or local, state, or federal regulations or statutes.
At-Will Employment
*
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