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?

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

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.

Other

CDL License Info

License Number

CDL License State

Drivers License Expiration Date

MonthDayYear

Endorsements

Do you possess a valid TWIC?

Which of the following do you have experience with?

Are you currently Employed?

Have you worked for this company before

Driving Experience

Most Common Trailer Length Hauled

Please check all states driven in the past 5 years

List any special driver related courses or training.

Other

Which safe driving awards do you hold and from whom?

Other

List any special equipment experience.

Other

Highest High School Grade Completed

Highest College Level Completed

Last School Attended

State

Traffic Accidents

Have you had a accident in the past 3 years?

Traffic Accident 1

Please provide a date

Type of Accident

Type of Vehicle

Fatalities

Injuries

Hazardous Material Release

Traffic Accident 2

Please provide a date

Type of Accident

Type of Vehicle

Fatalities

Injuries

Hazardous Material Release

Traffic Convictions

Have you had a traffic conviction in the past 3 years?

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)?

If yes, please explain

Have you ever had your license suspended, denied and/or revoked?

If yes, please explain

Background

Have you ever been convicted of a felony? ( Conviction will not necessarily disqualify an applicant from employment. )

If yes, please explain

Have you ever tested positive on a pre-employment drug screen or a random drug screen

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

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)