NewApp

Name*

First NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Duration*
If less than three years at current address please provide address
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Duration
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Duration
Social Security Number
Date of Birth*

MonthDayYear
Can you provide proof of age?*

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

YesNo
E-mail
Phone Number*

Area CodePhone Number
Is there any reason you many be unable to perform the functions of the job for which you have applied as described in the job description provided? If yes, explain if you wish.*

NoOther
CDL License Info
License Number
CDL License State
Drivers License Expiration Date

MonthDayYear
Endorsements

TankerHazmatDouble & TriplesX EndorsementNone
Do you possess a valid TWIC?

YesNo
Which of the following do you have experience with?*

STRAIGHT TRUCKTRACTOR AND SEMI TRAILERTRACTOR - TWO TRAILERSTRACTOR - THREE TRAILERSMOTOR-COACH - SCHOOL BUS 8+MOTOR-COACH - SCHOOL BUS 16+Other
Are you currently Employed?
Have you worked for this company before*

YesNo
Driving Experience*
Most Common Trailer Length Hauled
Please check all states driven in the past 5 years*

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
List any special driver related courses or training.*

N/AOther
Which safe driving awards do you hold and from whom?*

N/AOther
List any special equipment experience.

N/AOther
Highest High School Grade Completed*

147102581136912
Highest College Level Completed
Last School Attended*
State*
Traffic Accidents
Have you had a accident in the past 3 years?*

YesNo
Traffic Accident 1
Please provide a date
Type of Accident
Type of Vehicle
Fatalities
Injuries
Hazardous Material Release

YesNo
Traffic Accident 2
Please provide a date
Type of Accident
Type of Vehicle
Fatalities
Injuries
Hazardous Material Release

YesNo
Traffic Convictions
Have you had a traffic conviction in the past 3 years?*

YesNo
Traffic Conviction 1
Please provide a date
Type of Vehicle
Location
Conviction
Penalty
Traffic Conviction 2
Please provide a date
Type of Vehicle
Location
Conviction
Penalty
Have you ever been convicted of driving under the influence of drugs/alcohol(DWAI/DUI/DWI)?*

YesNo
If yes, please explain
Have you ever had your license suspended, denied and/or revoked?*

YesNo
If yes, please explain
Background
Have you ever been convicted of a felony? ( Conviction will not necessarily disqualify an applicant from employment. )*

YesNo
If yes, please explain
Have you ever tested positive on a pre-employment drug screen or a random drug screen*

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

YesNo
Employment Information

Start with your most current Employer.
Employment History

Driver applicants operating in the interstate commerce must provide the following information on all employers during the previous 3 years. Enter the information for your previous employer proving as much detail as possible. Failure to provide adequate or required detail will inhibit the ability to obtain the necessary background information.

CDL holders are required to list additional 7 years previous employer information for a total of 10 years listed on their application. Account for any breaks in employment by indication any time not working as a result of lay off, personal leave, unemployment, medical leave, etc. Note: Self Employment may require tax records to verify your employment for the period of time indicated as self-employed.
Employer 1
Company Name*
Position*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Contact Person*
Type of Logs used*
Salary*
Reason for Leaving*
Start Date*
End Date*
Were you subject to FMCSR's while employed?*
Was your job designated as a safety sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?*
If gap between employers, indicate reason.
Employer 2
Company Name
Position
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Contact Person
Type of Logs used
Salary
Reason for Leaving
Start Date
End Date
Were you subjest to FMCSR's while employed?
Was your job designated as a safety sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?
If gap between employers, indicate reason.
Employer 3
Company Name
Position
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Contact Person
Type of Logs used
Salary
Reason for Leaving
Start Date
End Date
Were you subject to FMCSR's while employed?
Was your job designated as a safety sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?
If gap between employers, indicate reason.
Employer 4
Company Name
Position
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Contact Person
Type of Logs used
Salary
Reason for Leaving
Start Date
End Date
Were you subject to FMCSR's while employed?
Was your job designated as a safety sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?
If gap between employers, indicate reason.
Employer 5
Company Name
Position
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Contact Person
Type of Logs used
Salary
Reason for Leaving
Start Date
End Date
Were you subject to FMCSR's while employed?
Was your job designated as a safety sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?
If gap between employers, indicate reason.
I understand my employer Heads Up Racing Inc. may request for lawful purposes, background information about me from a consumer reporting agency in connection with my employment and/or insurance application as applicable. These background reports may be obtained at any time after receipt of this authorization and, if hired or engaged by the company, throughout my employment of contract period.

The types of information that may be obtained include, but are not limited to: social security number verification; address history; criminal records and history; public court records; driving records; accident history; prior drug and alcohol history; worker’s compensation claims; educations history verification (e.g. dates of attendance, degrees obtained); employment history verifications (e.g. dates of employment, reasons for termination, etc.); professional and/or personal reference checks; professional licensing and certification checks; drug/alcohol testing results, drug/alcohol history in violations of law and/or company policy; other information bearing my character, general reputation, personal characteristics, mode of living and credit standing.

This information may be obtained from private, public record sources, appropriate government agencies, educational institutions, former employers, and other information sources.

I know I may request more information about the nature and scope of any investigative consumer reports by contacting the Company. My signature below certifies my receipt of my summary of rights under the fair credit reporting act.
Signature
References:

Federal Motor Carrier Safety Regulations: Sections 382.413, 391.23, and 391.25

Fair Credit Reporting Act: Sections 604 (b) (A) and 607, Public Law 91-508, as amended by the Consumer Reporting Act of 1996 (Title ll, Subtitle D, Chapter 1, of Public Law 104-208)
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