Employment Application

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APPLICANT INFORMATION

Position(s) Applied for*

Name*

First Middle Last

Maiden / Other Names

Phone*

Email*

Address*

Street Address City State ZIP Code

How Long? (yr./mo.)*

0 of 10 max characters

Previous Addresses*

Street

City

State & Zip Code

How Long? (yr./mo.)

Social Security No.*

Date Of Birth*

MM slash DD slash YYYY

Sex / Gender*

Race*

Place of Birth

Do you have the legal right to work in the United States?*

Yes

Can You Provide Proof Of Age*

Yes

Have you worked for this company before?*

Yes

Where?*

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Rate of Pay*

Position*

Reason for leaving*

Are You Now Employed?*

Yes

If not, how long since leaving last employment?*

Who referred you?

Rate of pay expected*

Have you ever been bonded?

Yes

(Answer only if a job requirement)

Name of bonding company*

Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]?*

Yes

If yes, explain if you wish

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 addi tional 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*

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Address*

Street Address Address Line 2 City State ZIP Code

Position Held*

0 of 15 max characters

Salary/Wage*

0 of 15 max characters

Contact Person*

Phone Number*

Reason For Leaving*

Were You Subject To The FMCSRs† While Employed?*

Yes

Was your job designated a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?*

Yes

Employer Name

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Position Held

0 of 15 max characters

Salary/Wage

0 of 15 max characters

Contact Person

Contact Phone

Reason For Leaving

Were You Subject To The FMCSRs† While Employed?

Yes

Was your job designated a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Yes

Employer Name

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Position Held

0 of 15 max characters

Salary/Wage

0 of 15 max characters

Contact Person

Phone Number

Reason For Leaving

Were You Subject To The FMCSRs† While Employed?

Yes

Was your job designated a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Yes

Employer Name

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Position Held

0 of 15 max characters

Salary/Wage

0 of 15 max characters

Contact Person

Phone Number

Reason for Leaving

Were you subject to the FMCSRs+ while employed?

Yes

Was your job designated a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Yes

Employer Name

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Position Held

0 of 15 max characters

Salary/Wage

0 of 15 max characters

Contact Person

Phone Number

Reason for Leaving

Were you subject to the FMCSRs+ while employed?

Yes

Was your job designated a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Yes

Employer Name

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Position Held

0 of 15 max characters

Salary/Wage

0 of 15 max characters

Contact Person

Phone Number

Reason for Leaving

Were you subject to the FMCSRs+ while employed?

Yes

Was your job designated a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Yes

†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.

*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.

ACCIDENTS & CONVICTIONS

Accident record for past 3 years or more (attach sheet if more space it needed) If none, write none*

Date

Nature of Accident

Fatalities

Injuries

HAZMAT Spill

Traffic conviction and forefeitures for the past 3 years (other than parking violations) if non, write none

Location

Date

Charge

Penalty

(Attach sheet if more space is needed)

EXPERIENCE AND QUALIFICATIONS - DRIVER

List all driver licenses or permits held in the past 3 years*

State

License No.

Class

Endorsements

Expiration Date

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

Yes

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

Yes

IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS*

DRIVING EXPERIENCE

STRAIGHT TRUCK*

Yes

CIRCLE TYPE OF EQUIPMENT

DATES FROM (M/Y) TO (M/Y)

APPROX. NO. OF MlLES (TOTAL)

TRACTOR AND SEMI-TRAILER*

Yes

CIRCLE TYPE OF EQUIPMENT

DATES FROM (M/Y) TO (M/Y)

APPROX. NO. OF MlLES (TOTAL)

TRACTOR - TWO TRAILERS*

Yes

CIRCLE TYPE OF EQUIPMENT

DATES FROM (M/Y) TO (M/Y)

APPROX. NO. OF MlLES (TOTAL)

TRACTOR - THREE TRAILERS*

Yes

CIRCLE TYPE OF EQUIPMENT

DATES FROM (M/Y) TO (M/Y)

APPROX. NO. OF MlLES (TOTAL)

MOTORCOACH-SCHOOLBUS*

Yes

More than 8 passengers

CIRCLE TYPE OF EQUIPMENT

DATES FROM (M/Y) TO (M/Y)

APPROX. NO. OF MlLES (TOTAL)

MOTORCOACH-SCHOOLBUS*

Yes

More than 15 passengers

CIRCLE TYPE OF EQUIPMENT

DATES FROM (M/Y) TO (M/Y)

APPROX. NO. OF MlLES (TOTAL)

OTHER*

Yes

CIRCLE TYPE OF EQUIPMENT

DATES FROM (M/Y) TO (M/Y)

APPROX. NO. OF MlLES (TOTAL)

LIST STATES OPERATED IN FOR LAST FIVE YEARS*

SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

EXPERIENCE AND QUALIFICATIONS - OTHER

SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION

LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)

EDUCATION

HIGHEST GRADE COMPLETED*

High School 1

High School 2

High School 3

High School 4

College 1

College 2

College 3

College 4

LAST SCHOOL ATTENDED (NAME)*

WAIVERS & RELEASES

TO BE READ AND SIGNED BY APPLICANT

Authorization*

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, health care 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 inter view(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

Contact Release*

I understand that information 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.

Background Check*

By signing this waiver I certify that all of the personal identifying information provided herein is accurate. I understand that by providing this information and signing this document I agree to allow my employer/prospective employer to receive a copy of my report through ACJIC.

I understand that ABC reports may contain reported felony and misdemeanor arrests, violations, and court records included in databases maintained by the State of Alabama. I further understand that ABC reports contain personal information from motor vehicle records included in records maintained by the State of Alabama. Personal information is information that identifies the individuals on whom the ABC report is conducted, including photograph, social security number, driver identification number, name, address, telephone number, and medical or disability information. Juvenile, youthful offender, sealed and/or expunged records will not appear on any ABC report.

I further understand that any information supplied on an ABC report is derived from a name-based search using only the identifiers submitted by my employer/prospective employer or this employer’s authorized Third Party User based on the information provided by me on this form. ACJIC in no way guarantees that criminal history record information provided through this system is for the person named in the request. Fingerprint based searches are the most reliable way to conduct criminal record checks and the least likely to result in either a false positive or false negative search result. This is not a fingerprint based search.

I understand that this waiver may be sent to ACJIC electronically in a form prescribed by ACJIC.

I understand that the results of my ABC report may be verified by submitting fingerprints to the Alabama Department of Public Safety.

Certification*

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.

Front of Driver's License*

Max. file size: 256 MB.

Back of Driver's License*

Max. file size: 256 MB.

Certifications & Other Documentation

Drop files here or

Max. file size: 256 MB.

Signature*

Date*

MM slash DD slash YYYY

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Comments

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Need Help Now? Call (205) 251-4060

Employment Application

APPLICANT INFORMATION

Employment History

ACCIDENTS & CONVICTIONS

EXPERIENCE AND QUALIFICATIONS - DRIVER

DRIVING EXPERIENCE

EXPERIENCE AND QUALIFICATIONS - OTHER

EDUCATION

WAIVERS & RELEASES