driver application

Reset Form
DRIVER APPLICATION
The Civil Rights Act of 1964 prohibits discrimination because of race,
color, religion, sex or national origin. PL 90-202 prohibits discrimination
because of age. The Americans with Disabilities Act prohibits
discrimination because of disability.
Office Use Only—
Program Type:_______________________
Recruiter:___________________________
Target Date:_________________________
NOTE: Read and complete all portions of this application. Incomplete applications may
be delayed or rejected.
PERSONAL INFORMATION
Date:____________________
Home Phone:_____________________
Name:_________________________________ ________________________ _________________
Message Phone:__________________
(Last)
(First)
(MI)
Present Address:______________________________________________ _______________ _______ __________
Street
City
State
Years/Months
______________________________________________ _______________ _______ __________
Street
City
(Addresses
_____________ ______________________________________________ _______________
for past 5
Street
City
years)
_____________ ______________________________________________ _______________
Street
City
State
Years/Months
Years/Months
City
State
Social Security No.________________________________ *Date of Birth________________________
Have you ever been known by another name (maiden, nickname, etc.)?
Dates:_______________
☐ Yes ☐ No
How long?______ _______
Zip Code
Years/Months
______________________________________________ _______________ _______ __________
Street
How long?______ _______
Zip Code
_______ __________
State
How long?______ _______
Zip Code
_______ __________
State
How long?______ _______
Zip Code
How long?______ _______
Zip Code
Years/Months
*The DOT requires we ask your age and that
all drivers be a minimum of 21 years old.
Name(s):________________________________________
Explain:_________________________________________________________________________________________
How did you hear about us? (Check as many as apply.)
☐ Magazine:_________________________________________
☐ School
☐ Rehire
☐ Brochure/Poster
☐ Other:__________________________________________
☐ Internet
☐ Newspaper:________________________________________________________________________
☐ TV
☐ Radio
☐ Sign on NTB Trailer
☐ Seminar
☐ Referred by NTB Employee:_________________________________________________________________________________
Pay expected_______________________________________________
Have you been trained in Hazardous Materials handling?
☐ Yes
☐ No
Have you ever provided driving services to NTB?
☐ Yes
☐ No
Have you previously applied for employment with NTB?
☐ Yes
☐ No
Present level pay_______________________________________
MILITARY SERVICE RECORD
Have you served in the U.S. armed forces? ☐Yes ☐No Branch:
Dates of service: From____________ To____________
☐ Army
☐ Navy
Current duty status:
If active, Reserve or Guard: Duty phone # _____________________________
☐ Air Force
☐ Active
☐ Marines
☐ Inactive
☐ National Guard ☐ Reserves
☐ Discharged
Person to contact ________________________________________
EDUCATION
Enter highest year completed:
Do you have: High School Diploma? ☐ Yes ☐ No
Grade School:_____
High School:_____
G.E.D. (Grade Equivalency Diploma)? ☐ Yes ☐ No
College:_____
Last date attended High School________
List any training program presently attending or completed (truck driving schools, etc.):
____________________________________ ________________ ______ ________________________
School Name
City
State
Phone Number
From__________
Month/Year
To______________
Month/Year
PERSONAL HISTORY FOR PAST 10 YEARS
Begin with your present experience and work backward in order, listing all of your employers, driving school and other training programs, periods
of military service, self-employment and unemployment for at least 10 years. All time must be accounted for. Use Additional Information
section if necessary. Fill in all blanks. Leave NO blanks or gaps in time for past 10 years.
MOST RECENT EMPLOYER
PERIOD OF UNEMPLOYMENT (if any) DATES: From (Month/Year) _____________________ To _____________________
Dates: From ___________ To ___________
Postion Held ______________________________________________________
Company ________________________________________
Avg. Weekly Earnings ________________________
Address _________________________________________
Reason for Leaving ________________________________________________
City _________________ State ______ Zip ____________
If Experienced, Type of Trailer Pulled __________________________________
Phone __________________________________________
Type of Equipment Driven __________________________________
Supervisor _______________________ Number of Accidents ________ Total Miles ______________________________________________
Full or Part-Time _______ Hours or Miles/Week __________ State/Regions You Drove In __________________________________________
Were you subject to the FMCSRs while employed? ☐ Yes ☐ No
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? ☐ Yes ☐ No
MOST RECENT EMPLOYER
PERIOD OF UNEMPLOYMENT (if any) DATES: From (Month/Year) _____________________ To _____________________
Dates: From ___________ To ___________
Postion Held ______________________________________________________
Company ________________________________________
Avg. Weekly Earnings ________________________
Address _________________________________________
Reason for Leaving ________________________________________________
City _________________ State ______ Zip ____________
If Experienced, Type of Trailer Pulled __________________________________
Phone __________________________________________
Type of Equipment Driven __________________________________
Supervisor _______________________ Number of Accidents ________ Total Miles ______________________________________________
Full or Part-Time _______ Hours or Miles/Week __________ State/Regions You Drove In __________________________________________
Were you subject to the FMCSRs while employed? ☐ Yes ☐ No
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? ☐ Yes ☐ No
MOST RECENT EMPLOYER
PERIOD OF UNEMPLOYMENT (if any) DATES: From (Month/Year) _____________________ To _____________________
Dates: From ___________ To ___________
Postion Held ______________________________________________________
Company ________________________________________
Avg. Weekly Earnings ________________________
Address _________________________________________
Reason for Leaving ________________________________________________
City _________________ State ______ Zip ____________
If Experienced, Type of Trailer Pulled __________________________________
Phone __________________________________________
Type of Equipment Driven __________________________________
Supervisor _______________________ Number of Accidents ________ Total Miles ______________________________________________
Full or Part-Time _______ Hours or Miles/Week __________ State/Regions You Drove In __________________________________________
Were you subject to the FMCSRs while employed? ☐ Yes ☐ No
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? ☐ Yes ☐ No
MOST RECENT EMPLOYER
PERIOD OF UNEMPLOYMENT (if any) DATES: From (Month/Year) _____________________ To _____________________
Dates: From ___________ To ___________
Postion Held ______________________________________________________
Company ________________________________________
Avg. Weekly Earnings ________________________
Address _________________________________________
Reason for Leaving ________________________________________________
City _________________ State ______ Zip ____________
If Experienced, Type of Trailer Pulled __________________________________
Phone __________________________________________
Type of Equipment Driven __________________________________
Supervisor _______________________ Number of Accidents ________ Total Miles ______________________________________________
Full or Part-Time _______ Hours or Miles/Week __________ State/Regions You Drove In __________________________________________
Were you subject to the FMCSRs while employed? ☐ Yes ☐ No
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? ☐ Yes ☐ No
DRIVING EXPERIENCE
Class of Equipment
Straight Truck
Tractor and Semi-Trailer
Tractor – Two Trailers
Other
Type of Equipment
Date From
Date To
Approximate # of Miles
MOTOR VEHICLE LICENSES
List all driver licenses held in the past 3 years (CDL-A with HazMat required):
State
License Number
Type
Expiration Date
ACCIDENT RECORD (IF NONE, WRITE NONE)
List all accident involvements with any vehicle for past 3 years (even if not at fault):
Nature of Accident
Were You
Date
Type of Vehicle
(Head-on, Rear-end, Upset, Etc.)
At Fault?
Were You
Ticketed?
Number of
Fatalities
Number of
Injuries
Hazardous
Material Spill
TRAFFIC CONVICTIONS (IF NONE, WRITE NONE)
List all traffic convictions and forfeitures for the past 7 years (in any motor vehicles, other than parking violations):
Date
Location (State)
Violation (If speeding, show rate of speed)
Penalty/Amount of Fine
Have you ever been fired from a job?................................................................................................................... ☐ Yes ☐ No Date_______________
Have you ever been convicted of a felony? (Answering YES to this question will not automatically
disqualify you from being hired) ............................................................................................................................. ☐ Yes ☐ No Date_______________
Has any license, permit or privilege ever been suspended or revoked? ............................................................... ☐ Yes ☐ No Date_______________
In the last seven (7) years, have you been convicted of reckless driving or are any charges pending? .................☐ Yes ☐ No Date_______________
In the last seven (7) years, have you been convicted for driving while under the influence of alcohol
or controlled substances?....................................................................................................................................... ☐ Yes ☐ No Date_______________
In the last three (3) years, have you ever tested positive for, or refused to take, a pre-employment or random
drug and/or alcohol test?........................................................................................................................................ ☐ Yes ☐ No Date_______________
In the last three (3) years, have you been convicted of careless driving?............................................................. ☐ Yes ☐ No Date_______________
If you answered YES to any of the above, please explain:
GENERAL INFORMATION
Are you a U.S. citizen?
☐ Yes ☐ No
Do you have a current, legal work permit?
If no, do you have the legal right to remain permanently in the U.S.?
☐ Yes ☐ No
☐ Yes ☐ No
EMERGENCY NOTIFICATION
In case of emergency, notify: _______________________________________________________________________________________
Phone Number: ________________________________
Relationship:____________________________________________________
REFERENCES
List two people able to verify employment and personal history, such as co-workers, customers, friends, or neighbors. Do NOT use relatives or former
employers.
Name _____________________________
City______________ State________
How long have you known him/her?_________________
Telephone____________________________ Place of Employment_____________________________ Occupation_________________________
Name _____________________________
City______________ State________
How long have you known him/her?_________________
Telephone____________________________ Place of Employment_____________________________ Occupation_________________________
PHYSICAL REQUIREMENTS FOR POSITION
All applicants must meet the D.O.T. physical qualification requirements (Part 391, Sub Part E) which are as follows:
No loss of foot, leg, hand, arm (unless the DOT has waived this requirement).
No impairment of:
• A hand or finger that interferes with prehension or power grasping.
• An arm, foot or leg that interferes with ability to perform normal tasks associated with operating a motor vehicle (unless the DOT has
waived this requirement).
No established medical history or current clinical diagnosis of:
• Diabetes mellitus currently requiring insulin for control.
• Epilepsy or any other condition likely to cause loss of consciousness or any loss of ability to control a motor vehicle.
No established medical history or clinical diagnosis of any of the following likely to interfere with the ability to control, operate or drive a motor
vehicle safely:
• Respiratory dysfunction.
• Rheumatic, arthritic, orthopedic, muscular, neuromuscular or vascular disease.
No current clinical diagnosis of:
• Myocardial infarction (heart attack).
• Angina pectoris (chest pain).
• Coronary insufficiency (decrease in blood flow through the coronary blood vessels).
• Thrombosis (blood clots).
• Any other cardiovascular disease known to be accompanied by syncope (fainting), dyspnea (shortness of breath), collapse or congestive
heart failure.
• High blood pressure likely to interfere with the ability to operate a motor vehicle safely.
• Alcoholism.
No use of Schedule 1 drug, an amphetamine, narcotic, or any other habit-forming drug except prescribed drugs that do not interfere with the ability
to drive.
No mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with the ability to operate a motor vehicle safely.
NOTE: If you do not meet the above physical requirements you will not be able to do the job for which you are applying.
Are you physically able, with or without a reasonable accommodation:
To operate a commercial motor vehicle for long periods of time? ................................................................................................ ☐ Yes ☐ No
To walk, bend, reach, push, pull, stoop, grasp, and lift when moving freight weighing up to 75 pounds per piece from
floor level to floor level distance of up to 53 feet for extended periods of time? ........................................................................... ☐ Yes ☐ No
To climb in and out of an over-the-road tractor, 4 to 6 feet, 8 to 10 times per day? ..................................................................... ☐ Yes ☐ No
To reach above shoulder level with both arms to load and unload freight for extended periods of time? ..................................... ☐ Yes
To complete written logs? .......................................................................................................................................................... ☐ Yes
To walk, bend, reach, push, pull, stoop, squat, and climb as necessary when conducting pre-trip inspections of a
tractor and trailer as in accordance with FMCSR Section 396.13? .............................................................................................. ☐ Yes
To fuel a tractor and trailer? . ...................................................................................................................................................... ☐ Yes
To walk, bend, reach, push, pull, stoop, squat, as well as grasp, lift and handle heavy equipment as necessary to
ensure safety during both the hooking and dropping process of tractor/trailer combinations? ..................................................... ☐ Yes
☐ No
☐ No
☐ No
☐ No
☐ No
TO BE READ AND SIGNED BY APPLICANT:
By completing and submitting this application, I
•
Authorize the Employer, its affiliates or its agent, to investigate my background, character, general reputation, record of convictions and charges
pending, and prior employment by contacting my prior employers, references or any other individuals or agencies Employer considers necessary;
•
Authorize Employer, my prior employers, references and any other individuals or agencies contacted by Employer to release any and all
information they may have regarding me and absolve those parties who provide information requested from any and all liability related to their
doing so;
•
Acknowledge elements of Employer’s affirmative action programs may be reviewed by any employee or applicant in the Human Resource
Department upon reasonable request during regular business hours;
•
Acknowledge that any employment offered to me is at the will of Employer and may be terminated by Employer at any time, with or without cause;
•
Acknowledge that I will be required and agree to submit to a physical examination and testing for drug/alcohol abuse as part of Employer’s
evaluation procedures and authorize release of my results to Employer and Employer’s use of those results in deciding whether I should be
offered employment (FMCSR Part 391, Sub Part E);
•
Acknowledge and agree that evidence of illegal drug/alcohol use during my employment may be grounds for immediate termination without notice
and without recourse;
•
Certify by my signature that I am able to read and speak the English language in accordance with Sub Part B, Sub Section 391.11(b)(2) of the
FMCSR;
•
Certify by my signature that all entries on this application and all information in it are true and complete to the best of my knowledge;
•
Agree that, if any of the information provided in this application changes, whether before or after employment, I will immediately provide Employer
with new and updated information;
•
Agree that not updating or providing false, misleading or incomplete statements in this application or in connection with Employer’s evaluation of
me as a candidate for employment is grounds for immediate termination of my employment, regardless of when such information is discovered.
Date ________________________ Signature ______________________________________ Print Name ___________________________________
Additional Information:
DISCLOSURE AND RELEASE
In connection with my application for employment (including contract for services) with you, I understand that consumer
reports which may contain public record information may be requested from HireRight, Tulsa, Oklahoma; NIC
Technologies, McLean, VA; or Vigillo, LLC, Portland, OR. These reports may include the following types of information:
names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further
understand that such reports may contain public record information concerning my driving record, workers’ compensation
claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such
records; as well as information from HireRight concerning previous driving record requests made by others from such
state agencies, and state provided driving records.
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THE
ABOVE REFERENCED GROUPS TO FURNISH THE ABOVE-MENTIONED INFORMATION.
I have the right to make a request to the above mentioned groups, upon proper identification, to request the nature and
substance of all information in its files on me at the time of my request, including the sources of information; and the
recipients of any reports on me which they have previously furnished within the two years period preceding my request. I
hereby consent to your obtaining the above information from the above mentioned groups, and I agree that such
information which they have to obtain, and my employment history with you if I am hired, will be supplied by them to other
companies which subscribe to their services.
I hereby authorize procurement or consumer report(s). If hired (or contracted), this authorization shall remain on file and
shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract)
period.
__________________________________________
________________________________________
Print Name
Social Security Number
__________________________________________
________________________________________
Applicant’s Signature
Date
____________________________________________________
Date of Birth
APPLICANT DUE PROCESS RIGHTS
I understand that the 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(i). I further 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______________________________________________
Date__________________
IMPORTANT NOTICE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
1. In connection with your application for employment with Nationwide Truck Brokers, Inc. (“Prospective Employer”), it 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
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.
The Prospective Employer cannot obtain background checks from FMCSA unless you consent in writing.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
2. I authorize Nationwide Truck Brokers, Inc. (“Prospective Employer”) 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 consenting to 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.
3. 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 am challenging a 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 for
adjudication.
4. Please note: 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 include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and
where those crashes were reported to the FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on
the PSP report. State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and
remain on a PSP report.
______________________________________________________________________________________________________
I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign
this consent form, 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.
Date: ______________________________________
_____________________________________________
Signature
_____________________________________________
Name (Please Print)
NOTICE: This form is made available to monthly account holders by NICT on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration
(FMCSA). Account holders are required by federal law to obtain a driver’s written or electronic consent prior to accessing the driver’s PSP report. Further, account holders
are required by FMCSA to use the language provided in paragraphs 1-4 of this document to obtain a prospective driver’s consent. The language must be used in whole,
exactly as provided. The language may be included with other consent forms or language at the discretion of the account holder, provided the four paragraphs
remain intact and the language is unchanged.
ETHNIC ORIGIN
Applicant Name: ______________________________ Date: _______________
NOTE: As part of our driver apprenticeship program the Department of Labor requests that we track the
following information in our applicant database. You are not required to provide this information and choosing
to “decline to respond” below will in no way affect your application status with NTB, Inc.
Please check one of the following:
Gender:
Male
Female
Ethnic Origin:
White (Not of Hispanic origin): All persons having origins in any of the
peoples of Europe, North Africa, or the Middle East.
Black (Not of Hispanic origin): All persons having origins in any of the
Black racial groups of Africa.
Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or
South American, or other Spanish culture or origin, regardless of race.
Asian or Pacific Islander: All persons having origins in any of the
original peoples of the Far East, Southeast Asia, the Indian
Subcontinent, or the Pacific Islands. This area includes, for example,
China, India, Japan, Korea, the Philippine Islands, Samoa and Hawaii.
American Indian or Alaskan Native: All persons having origins in any
of the original peoples of North America, and who maintain cultural
identification through tribal affiliation or community recognition.
Multi-Racial: All persons having parents of different races
Decline to respond
Additional Information: (This page is available to provide any pertinent supplementary information to the attached application.)