Timmons Transit-574108

Application for Employment
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com
How did you hear about us?
Have you worked for this company before?

YesNo
If so, when?
To be read and signed by the Applicant

I authorize you 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 after a conditional offer of employment has been extended.) I hereby release employers, schools, healthcare
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 40 CFR 391.23(d) and (e). I understand 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 on 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.

Driver Qualification List:
■ Applicant must have a valid Class A CDL
■ Applicant must be a minimum of 26 years of age
■ Applicant must be able to drive at night
■ Applicant must have a current Medical Examiner's Certificate
■ Applicant must not have more than 3 driving jobs in the last 12 months
■ Applicant must not have no more than 3 moving traffic violations in the last 36 months
■ Applicant must have no more than 2 preventable accidents in the last 5 years
■ Applicant must not have been convicted of a Felony
Applicant's Signature
Date

MonthDayYear
Date
Previous 3 Years Residency
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long?
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long?
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long?
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long?
Section 383.21 FMCSR states "No person who operates a commercial motor vehicle at any time have more than one Drivers' license". I certify that I do not have more than one motor vehicle license.

YesNo
Driving Experience

	Equipment	Type (van, tanker, flatbed, reefer, etc)	Year/Months	Approx # of Miles
Straight Truck
Tractor Trailer
Tractor - 2 trailers
Other

List any Safe Driving Awards you hold and from whom:

Accident Record for past 3 years or more -- if none, do not fill out

	Date	Nature of Accident (head-on, rear-end, lane change, etc.)	Fatalities	Injuries
1.
2.
3.

Traffic Convictions for the past 3 years -- if none, do not fill out

	Date	Location	Violation	Penalty
1.
2.
3.
4.

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

YesNo
If so, please give details?
Has any license, permit or privilege been suspended or revoked?

YesNo
If so, please give details?
Have you ever been convicted of a felony?

YesNo
If so, please give details?
Employment History

Applicants that desire to drive intrastate/interstate commerce must provide the following information on all employers during the previous three
years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial
three years (total of ten years employment record).
Last Employer
Date From

MonthDayYear
Date
Date To

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Were you subject to FMCSA Regulations while employed?

YesNo
Position Held:
Was your job designated as a Safety-Sensitive Function in any DOT Regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFL Part 40?

YesNo
Reason for Leaving?
Previous Employer
Date From

MonthDayYear
Date
Date To

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Were you subject to FMCSA Regulations while employed?

YesNo
Position Held:
Was your job designated as a Safety-Sensitive Function in any DOT Regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFL Part 40?

YesNo
Reason for Leaving?
Previous Employer
Date From

MonthDayYear
Date
Date To

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Were you subject to FMCSA Regulations while employed?

YesNo
Position Held:
Was your job designated as a Safety-Sensitive Function in any DOT Regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFL Part 40?

YesNo
Reason for Leaving?
It is agreed and understood that you or their agents may investigate my background to ascertain any and all information of concern to my record, whether same is or record or not, and I further release employers and persons named here in from all liability for any damages on account of their furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation my include an
investigating Consumer Report, including information regarding my character general reputation, personal characteristics and mode of living.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Applicant's Signature
Date

MonthDayYear
Date
Request for Previous Employment / Work History
I hereby authorize my previous employer to release the following information to Timmons Transit, including my drug and alcohol testing records as required by Sections 391.25 and 40.25(g) of the Federal Motor Carrier Safety Regulations.
Applicant's Name

First NameLast Name
Applicant's Signature

Release of Record of Alcohol and Drug Test Results

I do hereby authorize the Office of Driver Services to release my record of alcohol and drug test results to:

Timmons Transit Inc.
3116 Nestle Road
Jonesboro, AR 72401

WL Transport
3116 Nestle Road
Jonesboro, AR 72401

Signature
Date

MonthDayYear
Date
This consent is only valid for pre-employment and employment purposes as required by Arkansas Code Annotated 27-23-207.

Pre-Employment Screening Program (PSP)
Operator-Applicant Consent
Important Disclosure regarding background reports from the PSP online service

In connection with your application for employment with Timmons Transit, Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may , upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will conclude all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSA) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

Authorization

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Timmons Transit to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system
to the appropriate State or adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSA violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection
history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Signature
Date

MonthDayYear
Date

General Consent
I, hearby provide consent to Timmons Transit/WL Transport to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me ecists in the Clearinghouse.

I hearby give consent to Timmons Transit/WL Transport to conduct Limited Queries at their choosing while in their employ, for the duration of my employment.

I understand that if the limited query conducted by Timmons Transit/WL Transport indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to them without first obtaining additional specific consent from ,e

I further understand that if I refuse to provide consent to conduct a limited query of the Clearinghouse, Timmons Transit/WL Transport must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as requred by FMCSA's drug and alcohol program regulations.
Signature
Date

MonthDayYear
Date
Should be Empty:

Release of Record of Alcohol and Drug Test Results

General Consent