DRIVER'S APPLICATION

DRIVER'S APPLICATION
Applicant Name (print)*
Date of Application*

MonthDayYear
Date
Company
Address
City
State
Zip
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, veteran status, non-job related disability, or any other protected group status.
TO BE READ AND SIGNED BY APPLICANT

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 49 CFR 391.23(d) and (e I understand that 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 to 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.
Signature*

Clear
Date*

MonthDayYear
Date

APPLICANT TO COMPLETE
(answer all questions - please print)
Position(s) Applied for
Name

Last NameFirst NameMiddle Name
List your addresses of residency for the past 3 years.

CURRENT ADDRESS
Street*
City*
State*
Zip Code*
Phone*
yr./mo.*
PREVIOUS ADDRESS #1
Street
City
State & Zip Code
yr./mo.
PREVIOUS ADDRESS #2
Street
City
State & Zip Code
yr./mo.
PREVIOUS ADDRESS #3
Street
City
State & Zip Code
yr./mo.

APPLICANT TO COMPLETE
(answer all questions - please print)
Do you have the legal authority to work in the United States?*
Date of Birth (Required for Commercial Drivers)*

MonthDayYear
Date
Have you worked for this company before?*
Where?
From
To
Position
Reason for leaving
Who referred you?
Rate of pay expected
Have you ever been bonded? (Answer if a requirement)*
Name of bonding company
Can you perform, with or without reasonable accommodation, the essential functions of the job [as described in the attached job description]?*

YesNo

EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary)
Employer Name*
Address*
City*
State*
Zip*
Contact Person*
Phone Number*
Date From: Mo * Yr* (MM/YY format)
Date To: Mo * Yr* (MM/YY format)
POSITION HELD*
REASON FOR LEAVING*
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?*

YESNO
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?*

YESNO
*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Do you have another job to list?*

EMPLOYMENT HISTORY (CONTINUED)
NAME
ADDRESS
CITY
STATE
ZIP
CONTACT PERSON
PHONE NUMBER
Date From: Mo Yr (MM/YY format)
Date To: Mo Yr (MM/YY format)
POSITION HELD
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?

YESNO
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?

YESNO
*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Do you have another job to list?

EMPLOYMENT HISTORY (CONTINUED)
NAME
ADDRESS
CITY
STATE
ZIP
CONTACT PERSON
PHONE NUMBER
Date From: Mo Yr (MM/YY format)
Date To: Mo Yr (MM/YY format)
POSITION HELD
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?

YESNO
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?

YESNO
*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Do you have another job to list?

EMPLOYMENT HISTORY (CONTINUED)
NAME
ADDRESS
CITY
STATE
ZIP
CONTACT PERSON
PHONE NUMBER
Date From: Mo Yr (MM/YY format)
Date To: Mo Yr (MM/YY format)
POSITION HELD
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?

YESNO
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?

YESNO
*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Do you have another job to list?

EMPLOYMENT HISTORY (CONTINUED)
NAME
ADDRESS
CITY
STATE
ZIP
CONTACT PERSON
PHONE NUMBER
Date From: Mo Yr (MM/YY format)
Date To: Mo Yr (MM/YY format)
POSITION HELD
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?

YESNO
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?

YESNO
*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Do you have another job to list?

EMPLOYMENT HISTORY (CONTINUED)
NAME
ADDRESS
CITY
STATE
ZIP
CONTACT PERSON
PHONE NUMBER
Date From: Mo Yr (MM/YY format)
Date To: Mo Yr (MM/YY format)
POSITION HELD
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?

YESNO
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?

YESNO
*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Do you have another job to list?

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE

	Dates	Nature of Accident (Head-On, Rear-End, Upset, Etc.)	Fatalities	Injuries	Hazardous Material Spill
Last Accident
Next Previous
Next Previous

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
Location
Date
Charge
Penalty
Location
Date
Charge
Penalty
Location
Date
Charge
Penalty
EXPERIENCE AND QUALIFICATIONS - DRIVER
Driver licenses or permits in the past 3 years.
Issuer*
License No.*
Class*
Endorsement(s)*
Expiration Date*
Issuer
License No.
Class
Endorsement(s)
Expiration Date
Issuer
License No.
Class
Endorsement(s)
Expiration Date
Issuer
License No.
Class
Endorsement(s)
Expiration Date
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?*

YesNo
B. Has any license, permit or privilege ever been suspended or revoked?*

YesNo
If the answer to either A or B is yes, give details:

REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER

CONFIDENTIAL INFORMATION IS REQUESTED ON THIS FORM
Date of Application*

MonthDayYear
Date
Full Name*
Date of Birth*

MonthDayYear
Date
Previous Employer
Email
example@example.com
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Phone
Fax
I hereby authorize previous employers (listed on application) to release and forward the controlled substance and alcohol testing records within the previous 3 years from the date of my application noted above. In compliance with §40.25(g) and 391.23(h), release of this information must be made in written form that ensures confidentiality such as fax, email, or letter.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date

Hire Right Waiver

Must be completed by applicant
Trucking Industry - DOT D/A Disclosure and Authorization

Part 1 - Disclosure and Authorization for Release of Information for Employment Purposes - 49 CFR Part 391.23, DOT Drug and Alcohol Testing

In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to HireRight for the purpose of HireRight transmitting such records to the HireRight customer listed above. I understand that information/documents released pursuant to this Part is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation.

If any company listed below furnishes HireRight with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to HireRight, if applicable: (i) dates of my negative drug and/or alcohol tests and/ or tests with results below 0.04 during the previous three (3) years; and (ii) the name and telephone number of any substance abuse professional who evaluated me during the previous three (3) years.

List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, Social Security number and signature.
Previous DOT-Regulated Employer #1*
City*
State*
Telephone Number*
Previous DOT-Regulated Employer #2
City
State
Telephone Number
Previous DOT-Regulated Employer #3
City
State
Telephone Number
Previous DOT-Regulated Employer #4
City
State
Telephone Number
Previous DOT-Regulated Employer #5
City
State
Telephone Number
Previous DOT-Regulated Employer #6
City
State
Telephone Number
By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v)1 understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.
Print Applicant Name*
Applicant Signature*

Clear
Date*

MonthDayYear
Date
DOT Drug/Alcohol Disclosure and Authorization Trucking Industry-Employment Purpose

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23

Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.
- (a1) An inquiry into the driver's driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator's license or permit during those three years; and,
- (a2) An investigation of the driver's employment record during the preceding three years.
- (b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver's employment begins and be retained in compliance with 391.51.
- (c) Replies to the investigations of the driver's safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver's employment begins. This goes into effect after October 29, 2004.
- (d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.
- (e) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.
Drivers have the following rights:
1. The right to review information provided by previous employers.
2. The right to have errors in the information corrected by, the previous employer and for that previous employer to re-send the corrected information to the prospective employer.
3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver's request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver's Safety Performance History.

I acknowledge that I have read and understand the contents of this document.
Driver's Signature*

Clear
Date

MonthDayYear
Date
Driver Name (Printed)*

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse
I,*
First and Last Name
hereby give my consent to Shoreline Transfer Express, LLC to inquire a background check from FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse.

I understand that if the limited query conducted by Shoreline Transfer Express, LLC indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Shoreline Transfer Express, LLC without first obtaining additional specific consent from me.

I further understand that if I refuse to provide consent for Shoreline Transfer Express, LLC to conduct a limited query of the Clearinghouse, Shoreline Transfer Express, LLC must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

DRIVER'S APPLICATION

EMPLOYMENT HISTORY

EXPERIENCE AND QUALIFICATIONS - OTHER

EDUCATION

TO BE READ AND SIGNED BY APPLICANT

REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER

Hire Right Waiver

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse