New Hire Application

New Hire Application

For Mid-Atlantic Coil, LLC
Name *

First Name Middle Name Last Name Suffix
SSN *
Phone Number *

Area Code Phone Number
Email *
example@example.com
DOT or Non-DOT *

DOT Non-DOT
Coil or Snubbing?

Coil Snubbing
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State

Zip Code Country
Have you lived at this address for more than 3 years?

No Yes
Previous Address

Street Address

Street Address Line 2

City State

Zip Code Country

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job-related disability.
Do you have the legal right to work in the United States? *

Yes No
Can you provide Proof of Age? *

Yes No
Highest Grade Completed? *
Last School Attendance Dates *
Last School Attended Name *
Last School Attended Address *

Street Address

Street Address Line 2

City State / Province
Last School Attended Phone Number *

Area Code Phone Number
Have you worked here before? *

No Yes
When did you work here before?
Reason for Leaving?
Is there any reason you might know of that might inhibit you from performing the tasks related to the position for which you have applied? *

No Yes
Please explain based on what you understand those tasks to be.
Who referred you to this job?
Pay Rate Offered

Notice to Applicant: Before you continue in filling out the remainder of this application, we must inform you that the information you have provided so far, and any and all information you are about to disclose, in accordance with 49 CFR Part 391.21(b)(10) of the Federal Motor Carrier Safety Regulations (FMCSRs), may be used and your previous employers “will be” contacted for the purpose of investigating your safety performance history as required by 391.23(d) and 391.23(e) of the FMCSRs. If it has not already been provided for you, please ask for a written copy of your “due process rights” regarding all information obtained during the processing of your history as specified in 391.23(l).

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on the employers for whom the applicant operated such vehicle.

Note: List employers in reverse order, starting with the most recent. Add another sheet if necessary.
Are you currently employed? *

Yes No
Current Employer Company Name *
Current Employer Address *

Street Address

Street Address Line 2

City State

Zip Code Country
When did you start with your current employer? *

Month Day Year
Date
Current Position Title
Current Pay Rate
Are you subject to the FMCSRs in this position? §391.21(b)(10)(iv)(A) *

No Yes
Is this position designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing? §391.21(b)(10)(iv)(B) *

No Yes
Previous Employer Company Name *
When did you start with this employer? *

Month Day Year
Date
When did you leave this employer? *

Month Day Year
Date
Reason for leaving
Supervisor *
Previous Employer Address

Street Address

Street Address Line 2

City State

Zip Code Country
Phone Number

Area Code Phone Number
Previous Employer Company Name
When did you start with this employer?

Month Day Year
Date
When did you leave this employer?

Month Day Year
Date
Reason for leaving
Supervisor
Previous Employer Address

Street Address

Street Address Line 2

City State

Zip Code Country
Phone Number

Area Code Phone Number

Driving Record
Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials.
Have you been in an accident in the past three years? *

Yes No
Accident Record of Past Three (3) Years or More (Most Recent)
Previous
Previous
Have you been convicted of a traffic violation in the past three years? *

Yes No
Traffic Convictions for the Past Three (3) Years (other than parking violations) (Most Recent)
Previous Traffic Conviction
Previous Traffic Conviction
Experience and Qualifications - Drivers
State Issued
License #
Type
Expiration Date

Month Day Year
Date
Additional License
Specific Driving Experience
Straight Truck
Tractor - Trailer
Doubles/Triples
Other
List the states that you have operated in for the last five years
Show any special courses or training that will help you as a driver

To Be Read and Signed by Applicant
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 a 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)).

The prospective employee is required by Sec. 40.25(j) to respond to the following questions:
1. Have you ever tested positive or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? *

Yes No
2. If you answered yes, can you provide/obtain proof that you have successfully completed the DOT return-to-duty requirements? *

Yes No
This certifies that I completed this application, and that all entries and information documented by me are true and complete to the best of my knowledge. By my signature heretofore, I acknowledge having been given by this carrier which has presented me with this application, a statement of my right to due process as outlined by all parts of 49CFR Part 391.23 of the Federal Motor Carrier Safety Regulations effective October 29, 2004. Having made this acknowledgment, I therefore authorize you to make such previous employment and background investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary to arrive at a possible employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended). I understand that false or misleading information given in my application or interviews may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.
Signature *

Clear
Date Signed *

Month Day Year
Date

Application for Salaried Employment

Applicant must read and verify with initials and signature
I declare that the statements contained in this application are correct and understand that withholding information or making a false statement in this application and information submitted therewith or at any time during the application and pre-employment process will be the basis for my application not to be considered and/or dismissal. I authorize all employers, educators, and other firms or person(s) named herein to provide Mid-Atlantic Coil, (“the Company”) with information regarding my education, employment, and medical history and release all such individuals or entities from all liability for any damages that may result from releasing information regarding me.
Initials *
I understand that this application does not obligate the Company to offer me employment or to hire me. I further understand that if I am employed by the Company, my employment will be on an "at will" basis and may be terminated by the Company at any time with or without cause or notice. If I am employed, I understand that l will wear the prescribed personal protective equipment and will abide by all Federal, State, and Company procedures and regulations while working for the Company.
Initials *
I acknowledge that a copy of the Company's Dispute Resolution Program was available for my review at the location where l submitted this application. I acknowledge and understand that I am required to adhere to the Dispute Resolution Programs and its requirements for submission of all claims to process that may include mediation and/or arbitration and that if I refuse to sign below that my application will not be considered for employment. I further understand that my employment application submission with the Company constitutes my acceptance of the terms of this provision as a condition of employment consideration.
Initials *
I agree to a pre-employment drug test. Should the results or this test be unsatisfactory in the judgement of the Company, I will not be given further consideration for employment or any offer of employment will be withdrawn. I further authorize the doctor/medical review officer designated by the Company to release all information regarding this pre-employment drug test to the Company.
Initials *
This application will be considered active for (30) days.
Signature *

Clear
Date Signed *

Month Day Year
Date

Release Form & Employment Offer
I understand that if my application is considered, I will be required to successfuly complete a drug screening test, an agility test, and a physical examination, including procedures designed to determine whether I can safely perform the essential functions of the job for which I have applied (the “Test”).

The drug screen shall be conducted at the office of Don Baer at Quality Assured Companies.

The medical exam shall be conducted at the Pro Medical and includes, but is not limited to:

a. DOT Physical
b. Audiogram
c. Fit Test
d. Chest X-Ray with ILO Read & Reg Read

Upon completion of medical testing and review, my medical records shall be forwarded to Don Baer at Quality Assured Companies, 235 High Street, Morgantown, WV 26505. Don Baer will store the records and has permission to provide to the employer copies of the drug screen results, audiogram, and radiology review and report.

I understand that completing and passing the Test is required to ensure my safety and the safety of my coworkers. The Test will include lifting, pulling, and the performance of other strenuous activities designed to determine whether I can safely perform the essential functions of the job for which I have applied. I agree that the company and or individual(s) who administer the Test are required to provide me with the protocols and procedures involved in the performance of the Test. If I have any concerns or reservations whatsoever as to whether I can safely perform the Test, I will consult my personal physician prior to attempting the Test.

I also agree that if I feel lightheaded, dizzy, pain, discomfort, and/or any other abnormal symptoms at all during such test, I will immediately discontinue the examination and consult my personal physician prior to proceeding.

I hereby release Mid-Atlantic Coil, LLC, all of its subsidiaries and their respective officers, employees, agents, contractors, and representatives from any and all liability, claims, demands, and damages whatsoever, either in law or equity which may directly or indirectly result from my performance of the Test. To indicate my agreement with the above provisions, I have signed and dated this form below and have provided the following requested information.
Name *

First Name Middle Name Last Name Suffix
SSN *
***-**-****
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Signature *

Clear
Date *

Month Day Year
Date

Motor Vehicle Driver's Certification of Violations/ Annual Review of Driving Record
MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall, at least once every 12 months, require each driver it employs to prepare and furnish it with a list of violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months {Section 391.27}. Drivers who have provided information required by {Section 383.31} need not repeat that information on this form.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of or forfeited bond or collateral on account of any violation, which must be listed, he/she shall so certify {Section 391.27
Completed by Driver - Certification of Violations
Name *

First Name Middle Name Last Name Suffix
SSN *
***-**-****
Date of Employment
Driver's License Number
State Issued
Expiration Date

Month Day Year
Date
Home Terminal City/State
I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.
If you had no violations, check the following box:

No Violations
If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation other than those I have provided under Part 383 required to be listed during the past 12 months.
Signature *

Clear
Date of certification *

Motor Vehicle Driver's Certification of Compliance with Driver License Requirements
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, and 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 (“FMCSRs”) 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:
I. POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license.

a. 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.

II. NOTIFICATION OF LICENSE SUSPENSION, REVOCATION, OR CANCELLATION: Sections 392.42 and 383.33 othe Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocations 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 your employing motor carrier, and the state that issued your license (If the violations occur in a state other than the one which issued your license). The notification to both the employer and the state must be in writing.
The following license is the only one I will possess:
Name

First Name Middle Name Last Name Suffix
Driver's License Number *
Issuing State *
Expiration *
Driver Certification: I certify that I have read and understand the above requirements.
Driver's Signature *

Clear
Date *

Driver's Right to Due Process Regarding Investigation into Previous Safety Performance History and Drug and Alcohol Testing Verification
Under U.S. DOT §391.23(i) you have the following rights regarding the investigation information that will be provided:

Right to Review

You have the right to review information provided by previous employers. You must make a request in writing and it must be received no later than 30 days after being employed or being denied employment. We have five (5) business days after receipt of the written request, or after receiving the information from a previous employer, to provide this information to you. If you have not arranged to pick up or receive the requested records within thirty (30) days of us making them available, we may consider you have waived your request to review the records.

Right to Have Errors Corrected

  You have the right to have errors corrected in the information from your previous employer and for that previous employer to resend the corrected information to us. You must send the request for the correction directly to the previous employer that provided the records to us. The previous employer must either correct and forward the information to us or notify you within fifteen (15) days of receiving your request that it does not agree to correct the data. If the previous employer corrects the data and forwards it to us, we will notify you.

Right to Rebuttal

You have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and you cannot agree on the accuracy of the information. If you wish to rebut the information, you must send the rebuttal to your previous employer with instructions to include the rebuttal in that driver's safety performance history. Within five (5) business days of receiving a rebuttal, the previous employer must forward a copy of the rebuttal to us.

Timing

You have the right to send a rebuttal first, without making a request for a correction, or you may send the request for a correction, then a rebuttal.

Reporting to the FMCSA

You may (but are not required to) report failures of previous employers to correct information or include a rebuttal to the Federal Motor Carrier Safety Administration.

The above statement was received and read by me:
Signature *

Clear
Date *

Disclosure Statement
Disclosure to Consumer

As part of our hiring background and investigation, we may obtain consumer reports to prepare an investigative consumer report. The investigative consumer report may consist of contacting all listed prior employers to verify your employment history. It may also include, but not be limited to, credit information reports, criminal history reports and driving history records. Under the provisions of the Fair Credit Reporting Act (FCRA), 15 U.S.C. § 1681 et seq., before we can seek such reports, we must have your written permission to obtain the information. You have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation. You are also entitled to a copy of your Rights under the Fair Credit Reporting Act.

Authorization and Release to Obtain Information

Under the provisions of the Fair Credit Reporting Act (FCRA), 15 U.S.C. § 1681 et seq., the Americans with Disabilities Act and all applicable federal, state, and local laws, I hereby authorize and permit Mid‐Atlantic Coil, LLC to obtain a consumer report and/or an investigative consumer report that may include the following: my employment records, driving history records, criminal history, credit history, civil record, workers' compensati(post offer only), drug testing, verification of my academic and/or professional credentials, and information and/or copies of documents from any military service records.

I understand that an "investigative consumer report" may include information as to my character, general reputation, personal characteristics, and mode of living that may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information. I hereby release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information.

I understand and acknowledge that under provision of the FCRA, I may request a copy of any consumer report from the consumer reporting agency that compiled the report, after I have provided proper identification. I agree that a copy of this authorization has the same effect as an original. This authorization shall remain in effect over the course of my employment and reports may be ordered periodically during the course of my employment.

Current Address:
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Length of Residence
Date of Birth

Month Day Year
Date
Driver's License Number
Issuing State
Name

First Name Middle Name Last Name Suffix
SSN
***-**-****
Signature *

Clear
Date *
Attach a resume if you would like.

Browse Files

Cancel of
Should be Empty:

New Hire Application

Driving Record

Experience and Qualifications - Drivers

Specific Driving Experience

To Be Read and Signed by Applicant

Application for Salaried Employment

Release Form & Employment Offer

Motor Vehicle Driver's Certification of Violations/ Annual Review of Driving Record

Completed by Driver - Certification of Violations

Motor Vehicle Driver's Certification of Compliance with Driver License Requirements

Driver's Right to Due Process Regarding Investigation into Previous Safety Performance History and Drug and Alcohol Testing Verification

Disclosure Statement