Driver Long Application Indiana Office

Driver Long Application Indiana Office 2017-11-12T12:04:49+00:00
APPLICATION FOR EMPLOYMENT
USA DRIVERS, INC.
2930 SOUTH NAPPANEE STREET
ELKHART, IN  46517
PHONE:  574-522-3798     FAX:  574-522-3171
Date of application:

Email*:

Name*:



Address*:



How long at this address*:

Phone*:

Cell*:

Date of Birth*:

Social Security Number*:

Are you a citizen of the United States*:

If not, do you have a legal right to work in the United States*:

THREE YEAR ADDRESS HISTORY

1)*




2)




3)




DRIVERS LICENSES OF THE LAST 3 YEARS

1)*



2)



3)



Have you worked for this company before?*

Where?

Dates
to
Can you begin work immediately?

If not, when?

ACCIDENT RECORD FOR PAST 3 YEARS






TRAFFIC CONVICTIONS FOR THE PAST 3 YEARS

1)




2)




3)




EQUIPMENT EXPERIENCE

Tractor/TrailerLength of Experience
Dry Van
Reefer
Flat Bed
Low Boy
Drop Deck
Tanker
Dbls/Trpls
Dump Trailer
Car Hauler
Bus
Other
Straight TruckLength of Experience
Box
Reefer
Flat Bed
Tanker
Dump
Cement
Sanitation
Bus
Other

OTHER EXPERIENCE or CERTIFICATIONS (Check all that apply)


ForkliftMoffetteBoom TruckRoll offTWICOther

MILITARY STATUS

Have you served in the U.S. Armed Forces?

Branch

From to
Date of discharge:

Reserve Status:

EDUCATION

Circle highest grade completed:
123456789101112
College
1234
Last school attended:


PAST EMPLOYMENT RECORD

Please list all full-time and part-time employment during the past 10 years. Start with the current or most recent employer and workbackwards. The address must include street, city, state and zip code. If you drove as, or for, an owner-operator, list the company the vehicle was leased to as employer.

MOST RECENT EMPLOYER

DATES to

Name*:

Phone*:

Address*:

City*:

State*:

Zip*:

Position Held*:



Number of states driven*:

Number of accidents*:

Subject to FMCSR regulations*: YesNo

Subject to drug/alcohol testing requirements*: YesNo
Equipment*:
Straight truckSemi
Type of trailer*:
Dry VanReeferFlatbedTankerDumpCementOther

Commodities hauled*:

Reason for leaving*:


List dates of unemployment*: to
PREVIOUS EMPLOYER

DATES to

Name:

Phone:

Address:

City:

State:

Zip:

Position Held:



Number of states driven:

Number of accidents:

Subject to FMCSR regulations: YesNo

Subject to drug/alcohol testing requirements: YesNo
Equipment:
Straight truckSemi
Type of trailer:
Dry VanReeferFlatbedTankerDumpCementOther

Commodities hauled:

Reason for leaving:


List dates of unemployment: to
PREVIOUS EMPLOYER

DATES to

Name:

Phone:

Address:

City:

State:

Zip:

Position Held:



Number of states driven:

Number of accidents:

Subject to FMCSR regulations: YesNo

Subject to drug/alcohol testing requirements: YesNo
Equipment:
Straight truckSemi
Type of trailer:
Dry VanReeferFlatbedTankerDumpCementOther

Commodities hauled:

Reason for leaving:


List dates of unemployment: to
PREVIOUS EMPLOYER

DATES to

Name:

Phone:

Address:

City:

State:

Zip:

Position Held:



Number of states driven:

Number of accidents:

Subject to FMCSR regulations: YesNo

Subject to drug/alcohol testing requirements: YesNo
Equipment:
Straight truckSemi
Type of trailer:
Dry VanReeferFlatbedTankerDumpCementOther

Commodities hauled:

Reason for leaving:


List dates of unemployment: to
PREVIOUS EMPLOYER

DATES to

Name:

Phone:

Address:

City:

State:

Zip:

Position Held:



Number of states driven:

Number of accidents:

Subject to FMCSR regulations: YesNo

Subject to drug/alcohol testing requirements: YesNo
Equipment:
Straight truckSemi
Type of trailer:
Dry VanReeferFlatbedTankerDumpCementOther

Commodities hauled:

Reason for leaving:


List dates of unemployment: to
PREVIOUS EMPLOYER

DATES to

Name:

Phone:

Address:

City:

State:

Zip:

Position Held:



Number of states driven:

Number of accidents:

Subject to FMCSR regulations: YesNo

Subject to drug/alcohol testing requirements: YesNo
Equipment:
Straight truckSemi
Type of trailer:
Dry VanReeferFlatbedTankerDumpCementOther

Commodities hauled:

Reason for leaving:


List dates of unemployment: to
PREVIOUS EMPLOYER

DATES to

Name:

Phone:

Address:

City:

State:

Zip:

Position Held:



Number of states driven:

Number of accidents:

Subject to FMCSR regulations: YesNo

Subject to drug/alcohol testing requirements: YesNo
Equipment:
Straight truckSemi
Type of trailer:
Dry VanReeferFlatbedTankerDumpCementOther

Commodities hauled:

Reason for leaving:


List dates of unemployment: to
PREVIOUS EMPLOYER

DATES to

Name:

Phone:

Address:

City:

State:

Zip:

Position Held:



Number of states driven:

Number of accidents:

Subject to FMCSR regulations: YesNo

Subject to drug/alcohol testing requirements: YesNo
Equipment:
Straight truckSemi
Type of trailer:
Dry VanReeferFlatbedTankerDumpCementOther

Commodities hauled:

Reason for leaving:


List dates of unemployment: to

Were you referred by someone? YesNo

If so, by whom?

MOTOR VEHICLE RECORD



  • Have you ever been convicted, or forfeited a bond or collateral, or are any charges pending,for driving while intoxicated (DWI) or under the influence (DUI) of alcohol, a narcotic drug, amphetamines or derivatives thereof?
    YesNo
  • Have you ever refused testing, or had a positive, adulterated, or substituted test result in any pre-employment, random, return-to-duty, post-accident, or follow-up drug or alcohol test.
    YesNo
  • Have you ever been convicted, or forfeited a bond or collateral, or are any charges pending, for possession, sale or use of a narcotic drug, amphetamine, a derivative thereof, or any other unlawful drug or drug paraphernalia, or are any such charges pending.
    YesNo
  • Have you ever been convicted, or forfeited a bond or collateral, for leaving the scene of an accident, or are any such charges pending?
    YesNo
  • Have you ever been convicted, or forfeited a bond or collateral, for a felony involving a motor vehicle, or are any such charges pending?
    YesNo
  • In any 10 year period have you been convicted, or forfeited a bond or collateral for violating out-of-service orders in separate incidents?
    YesNo
  • In any 10 year period have you been convicted, or forfeited a bond or collateral for an out-of-service order while transporting hazardous materials required to be placarded or while operating a vehicle designed to transport more than 15 passengers?
    YesNo
  • Have you ever been convicted, or forfeited a bond or collateral for driving while license suspended, revoked, invalid or expired, or are any such charges pending?
    YesNo
  • Have you ever been convicted, or forfeited a bond or collateral for manslaughter, homicide, or negligent homicide by motor vehicle, or are any such charges pending?
    YesNo
  • Have you ever been convicted, or forfeited a bond or collateral for using a motor vehicle to commit a felony involving manufacturing, distributing, or dispensing a controlled substance, or are any such charges pending?
    YesNo
  • Have you ever been convicted, or forfeited a bond or collateral for speeding 15 mph or more Over the posted limit, or are any such charges pending?
    YesNo
  • Have you ever been convicted, or forfeited a bond or collateral for careless or reckless driving, or are any such charges pending
    YesNo
  • Have you ever been convicted, or forfeited a bond or collateral for making an improper or erratic traffic lane change, or for following the vehicle ahead too closely?
    YesNo
  • Have you ever been convicted, or forfeited a bond or collateral for motor vehicle traffic control violation that involved a fatal accident?
    YesNo
  • Have you ever operated a commercial motor vehicle without obtaining a CDL, or without a CDL in your possession, or without the proper CDL class of proper endorsements for the vehicle and cargo?
    YesNo
  • Have you ever been denied a license, permit, or privilege to operate a motor vehicle:
    If yes give details:
    YesNo
  • Has any license, permit or privilege ever been suspended or revoked:
    If yes give details:
    YesNo
  • Have you ever been convicted, or forfeited a bond or collateral for a railroad-highway crossing violation, or are any such charges pending?
    YesNo
  • Have you ever been granted a waiver under section 391-49 of the FMCSR pertaining to the loss of foot, leg, hand or arm?
    YesNo

RECORD OF CONVICTIONS



  • Have you ever pled guilty or been convicted of a felony?YesNo
  • Have you ever pled guilty or been convicted of a misdemeanor?YesNo
  • Do you currently have any criminal actions pending in which you are a defendant?YesNo
  • Are you currently on probation or parole?YesNo

CERTIFICATION

Applicant Authorization:
I hereby request and authorize USA Drivers, Inc., or any company that receives this application, to make, at any time, an investigation of my background for employment or contract for services purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, prior employment, accident or incident history, alcohol or drug test results, or failure to submit to an alcohol or drug test, reason for termination of employment, record of criminal convictions, deferred prosecutions, charges pending, educational background, or any other information about me which may reflect upon my potential for employment or contract for services. Further, I hereby authorize, fully understand and acknowledge, that any prior employers, prior lessors, educational institutions, organizations, entities, references, or any other individuals, agents or contractors, to release any and all information they may have regarding this application, and I agree to release them from any and all liability for supplying said information. In connection with my application for employment or contract for services, I understand that reports that may contain public record information may be requested from consumer reporting agencies. Although the completion of this application does not assure me of a position with any company or obligate any company in any way, I understand that if I am hired, false or misleading information given in my application or interview(s) may result in termination of my employment. Also, as an employee, I understand that I am required to obey all the rules and regulations of my employer. I have completed this application of my own free will and hold USA Drivers, Inc., harmless of all liability for providing it for my use, and hold any company that receives it harmless of all liability in regard to it. If hired by USA Drivers, Inc., this authorization shall remain on file and shall serve as ongoing authorization for USA Drivers, Inc., or for any company that receives this application to procure consumer reports at any time during my USA Drivers, Inc., employment period
Applicant Rights
I understand that I have the following rights: the right to review employment verification, accident records, alcohol and control substance testing results, and all other information provided by my previous DOT regulated employer(s); the right to have previous employer(s) correct errors in the information and to re-send the corrected information to a prospective employer, and the right to have a rebuttal statement attached to the alleged erroneous information, if any previous employer and I cannot agree on the accuracy of the information.
I have read and agree to the Applicant Authorization, and I have read and acknowledge receipt of the Applicant Rights notification.

DATE:

APPLICANT’S SIGNATURE (SIGN ON BOX BELOW)


* = Required Field