Non DOT Application for Employment

Non DOT Application for Employment
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, gender, national origin, sexual orientation, age, marital status, or non-job related disability.
General Information
Date of Application

MonthDayYear
1st Available Start Date

MonthDayYear
Name

PrefixFirst NameMiddle InitialLast NameSuffix
Date of Birth

MonthDayYear
Social Security Number
Please enter a valid social security number.Format: 000-00-0000.
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Position Applied For
Who referred you?

Address Information
Please list your addresses of residency for the past 3 years.
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Years
Add another address?
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Years
Add another address?
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Years
Add another address?
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Years

Employment History
Are you currently employed?
How long since leaving your previous employer?
Years
Is there any reason you might be unable to perform the functions for which you have applied?
You answered "Yes" to the previous question, please explain.

0/1000
Note: List employers in reverse order beginning with the most recent.
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Dates of Employment
Include Month and Year of Employment
Salary/Wage
Indicate hourly rate or annual salary
Name of Supervisor

First NameLast Name
Reason for leaving.

0/500
Was this position subject to Federal Motor Carrier Safety Regulations?
Was this position designated a "Safety-Sensitive Function" in any DOT mode subject to drug/alcohol requirements?
Add another employer?
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Dates of Employment
Include Month and Year of Employment
Salary/Wage
Indicate hourly rate or annual salary
Name of Supervisor

First NameLast Name
Reason for leaving.

0/500
Was this position subject to Federal Motor Carrier Safety Regulations?
Was this position designated a "Safety-Sensitive Function" in any DOT mode subject to drug/alcohol requirements?
Add another employer?
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Dates of Employment
Include Month and Year of Employment
Salary/Wage
Indicate hourly rate or annual salary
Name of Supervisor

First NameLast Name
Reason for leaving.

0/500
Was this position subject to Federal Motor Carrier Safety Regulations?
Was this position designated a "Safety-Sensitive Function" in any DOT mode subject to drug/alcohol requirements?
Add another employer?
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Dates of Employment
Include Month and Year of Employment
Salary/Wage
Indicate hourly rate or annual salary
Name of Supervisor

First NameLast Name
Reason for leaving.

0/500
Was this position subject to Federal Motor Carrier Safety Regulations?
Was this position designated a "Safety-Sensitive Function" in any DOT mode subject to drug/alcohol requirements?
Add another employer?
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Dates of Employment
Include Month and Year of Employment
Salary/Wage
Indicate hourly rate or annual salary
Name of Supervisor

First NameLast Name
Reason for leaving.

0/500
Was this position subject to Federal Motor Carrier Safety Regulations?
Was this position designated a "Safety-Sensitive Function" in any DOT mode subject to drug/alcohol requirements?
Add another employer?
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position(s) Held
Dates of Employment
Include Month and Year of Employment
Salary/Wage
Indicate hourly rate or annual salary
Name of Supervisor

First NameLast Name
Reason for leaving.

0/500
Was this position subject to Federal Motor Carrier Safety Regulations?
Was this position designated a "Safety-Sensitive Function" in any DOT mode subject to drug/alcohol requirements?
For additional employers, please send resume to hiring@patsoffroad.com.

Education
Highest Level of Education Completed
Area of Study
Indicate course study for college level courses
Last School Attended
Indicate school name, city, and state

Driving History
Dates and Nature of Accident, Fatalities, and/or Injuries

(Head-On, Rear-End, Upset, Etc.)
Last Accident (If none, type "None")

Describe nature of accident, date, and any injuries which took place.0/250
Add another accident?
Next Previous Accident

Describe nature of accident, date, and any injuries which took place.0/250
Add another accident?
Next Previous Accident

Describe nature of accident, date, and any injuries which took place.0/250
Traffic Convictions and Forfeitures for the Past 3 Years

(Other than Parking Violations)
Traffic Violation (If none, type "None")

Describe location, date, charge, and penalty of traffic conviction and/or forfeiture.0/250
Add another violation?
Traffic Violation

Describe location, date, charge, and penalty of traffic conviction and/or forfeiture.0/250
Add another violation?
Traffic Violation

Describe location, date, charge, and penalty of traffic conviction and/or forfeiture.0/250
Experience and Qualifications-Driver
Driver's License Number
State of Issue
Type of License
Endorsements
If none, enter "None"
Date of Expiration

MonthDayYear
If expired, put today's date and mark box below as expired.
Is your license expired?
Front of Driver's License
Back of Driver's License
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Please explain, in detail, why you have been denied a license, permit, or privilege to operate a motor vehicle.

0/250
Has any license, permit, or privilege ever been suspended or revoked?
Please explain, in detail, why you a license, permit, or privilege to operate a motor vehicle was suspended or revoked.

0/250
Driving Experience

If none, leave blank

Rows	Type of Equipment	Years of Experience	Approximate Miles Driven	State(s) Driven
Van, Tanker, Flatbed
Straight Truck
Tractor Trailer
Doubles or Triples
Motor Coach/School Bus
Other

Special courses or training that will help you as a driver

0/250
Safe driving awards (Include company where earned)

0/250
Trucking, transportation, or other experience that may help you with Pat's Offroad

0/250
Courses or training other than those listed in this application

0/250
Special equipment or technical materials you are familiar with

0/250

To Be Read and Signed by Applicants

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.

I authorize you to make such investigations and inquire of my personal, employment, financial, criminal or medical history and other related matters as may be necessary at 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, health care providers, and other personnel 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 interviews) may result in discharge. I also understand that I am required to abide by all rules and regulations of the company.
Signature
Today's Date

MonthDayYear

Release Disclosure and Authorization

In connection with my application for employment (Including contract for services) or at any time during my employment or contract, I agree to allow and hereby authorize Pat’s Offroad, Inc., to procure and compile a consumer report on me. This report may include information as to my character, reputation, mode of living, criminal history, military service, education, academic credentials, qualifications, employment history (Including job performance, experience, work habits and reason for termination, personal characteristics, credit and indebtedness, and motor vehicle driving record. This report may contain information from various public and private sources, including without limitation, corporations, courts and law enforcement agencies at the federal, state or local level, court records repositories, credit bureaus, departments of motor vehicles, past or present references, and any other source required to verify information that I have voluntarily supplied. I understand that I have the right to request additional disclosures as to the nature and scope of the investigative consumer report, Medical and workers compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws.

In accordance with the provisions of Section §604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter l, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections §382.413, §391.23, and §391.25 of the Federal Motor Carrier Safety Regulations.

By signing below, I agree to allow and hereby authorize, empower and release from all liability, without reservation, any party, person or agency including, without limitation, present and former employers, credit bureaus, educational Institution, corporations, court and law enforcement agencies at the federal, state or local level, courts record repositories, credit bureaus, departments of motor vehicles, educational institutions, the military and licensing or registration entities, contacted by Pat’s Offroad, Inc., to release information about me, including, without limitation, any of the Information described above. I agree that a fax, photocopy or electronic reproduction of this authorization is to be considered and accepted with the same authority as the original.
Legal Name

Legal First NameLegal Middle Name/InitialLegal Last Name
Other Names or Aliases Used (If none, type "None")
Signature
Today's Date

MonthDayYear
Date
These reports will be processed by: Pat's Offroad, Inc. 1925 Grand Ave Ste. 129 #70924 Billings, MT 59102 or (406) 213-8006.

Drug & Alcohol Program Consent Form

I hereby release the company, its officers, agents, employees, and attorneys from any and all liability that may in any way arise from, or in any way be connected with the company's drug & alcohol testing program, disciplinary program, or allowing me to continue to work with the company. I specifically waive any rights of action under any theory of law and the like including specifically but not limited to theories of negligent and/or intentional infliction of emotional distress, negligence, invasion of privacy, wrongful discharge, defamation, slander or any like or similar theory.

By my signature I acknowledge that I have read, understand, and agree to comply with the drug & alcohol testing program of Pat’s Offroad, Inc. As well as the U.S. Department of Transportation Regulations as contained in 49 CFR part 382.

I also understand that it is a condition of being considered for employment, and continued employment by the company that I agree to abide by the company policy. By my signature I consent to urine and/or breath testing for controlled substances and/or alcohol prior to and at any time during my employment when requested by my employer on a random or event triggered basis. I hereby specifically authorize the company to have all and immediate access to any and all of my urine and/or breath custody and control forms and the results thereof.

I understand and agree that I may not be under any degree of influence of alcohol or controlled substances at any time during my employ. Should any level of alcohol or controlled substance be detected in any of my breath or urine at any time while employed, the company shall have grounds for immediate termination of my employment. This authorization specifically covers any random or event triggered testing as may be required by the US. Department of Transportation Regulations or company policy.

Any positive test result or refusal to submit to any type of test shall constitute my automatic resignation from this company.
Signature
Today's Date

MonthDayYear
Date

Completed by Motor Carrier-Annual Review of Driving Record

Motor Carrier Instructions:

Review the Certification of Violations listed previously and other information described in Section §391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below.

I have hereby reviewed the driving record of the above named driver in accordance with Section §391.25 and find that he/she (Check one):

___________ Meets the minimum requirements for safe driving
___________ Is disqualified to drive a motor vehicle pursuant to Section §391.15
___________ Does not adequately meet satisfactory safe driving performance

____________________________________________________________________
Action taken with driver

_____________________________________________________
Name of Reviewing Authorized Representative

______________________________________________________
Title of Reviewing Authorized Representative

______________________________________________________
Signature of Authorized Representative

____________
Date
Should be Empty: