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Packaging & Logistics
Transportation
About MPH
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Employment
Step
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4
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APPLICATION FOR QUALIFICATION
(Attach a separate sheet of paper if necessary for any additional information requested
DRIVER’S RIGHTS TO REVIEW BACKGROUND CHECK - Dear Applicant:
Per FMCSR 391.21(d) Before an application is submitted, the motor carrier shall inform the applicant that the information he/she provides for the work history may be used, and the applicant's prior employers may be contacted, for the purpose of investigating the applicant's safety performance history information. The prospective motor carrier must also notify the driver in writing of his/her due process rights as specified in § 391.23(i) regarding information received as a result of these investigations. You the applicant have the following rights: (i) The right to review information provided by previous employers; (ii) 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 motor carrier; (iii) 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.
Driver Applicant Printed Name
Driver Applicant Signature
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Date
MM slash DD slash YYYY
Name
Last
First
Middle Initial
Phone
Current Address
Street
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
Duration
If at the above residence less than 3 years, list below all residences for the past 3 years.
Previous:
Street
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
Duration
Email Address
Cell Phone
Date of Birth
MM slash DD slash YYYY
* Drivers only to complete Date of Birth
Social Security No.
Phone
In Case Of Emergency Notify:
Name
Phone
Have you ever applied with this company before?
Yes
No
If yes, when?
Have you ever worked for this company under another name?
Yes
No
Name
Are you applying as a
company driver or an
owner operator?
(Check appropriate)
Ever applied with this company before?
Yes
No
If yes, When?
Are you currently employed?
Yes
No
If not, how long since leaving last employment?
Date you are available to start work?
How long are willing to be away from home?
List states operated in last 5 years
List safe driving awards and who presented by
How much home time will you need when you return?
How many miles or hours are you expecting per week?
How much do you expect to make per week (gross)?
Have you ever been convicted of a crime?
Yes
No
(A conviction does not automatically bar you from employment)
Are there any pending charges against you?
Yes
No
(Attach a separate sheet of paper if necessary)
If yes, explain for each entry: 1) Is it a conviction or pending charge? 2) Date of conviction or upcoming hearing, and 3) State in which convicted/charged.
EDUCATION
Circle highest grade completed:
1
2
3
4
5
6
7
8
9
10
11
12
College:
1
2
3
4
Last school attended
Name
Address
List special courses or training that will help you as a driver
EMPLOYMENT RECORD
Complete all data for EACH last employer COMPLETELY.
The U.S. Department of Transportation requires that the driver applicants show all employment for the past
three years.
Effective July 1, 1987, they
must also show commercial driver employment for the seven years preceding this three year period.
Sec. 391.21 (b) (10) (11).
Account for any gaps in employment between employers.
Last Employer:
Name
Phone
Address
Street
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
Position Held
Dates
Type Equip. Driven
Were you regulated by FMCSA during this job?
Yes
No
Areas Driven In
Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?
Yes
No
Reasons for Leaving
Second Last Employer:
Name
Phone
Address
Street
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
Position Held
Dates
Type Equip. Driven
Were you regulated by FMCSA during this job?
Yes
No
Areas Driven In
Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?
Yes
No
Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?
Yes
No
Reasons for Leaving
Third Last Employer:
Name
Phone
Address
Street
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
Position Held
Dates
Type Equip. Driven
Were you regulated by FMCSA during this job?
Yes
No
Areas Driven In
Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?
Yes
No
Reasons for Leaving
Fourth Last Employer:
Name
Phone
Address
Street
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
Position Held
Dates
Type Equip. Driven
Were you regulated by FMCSA during this job?
Yes
No
Areas Driven In
Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?
Yes
No
Reasons for Leaving
DRIVER EXPERIENCE & QUALIFICATION
LICENSES
State
License Number
Type/Endorsements
Expiration Date
List all licenses held in the last 3 years.
Do you currently hold more than one valid license?
Yes
No
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes
No
Has any license, permit or privilege ever been suspended or revoked?
Yes
No
Have you ever tested positive or refused a pre-employment drug test for a motor carrier that didn’t hire you in the last (3) three years?
Yes
No
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Reg’s (including Drug & Alcohol)?
Yes
No
If answered Yes to any of the above questions, please give details:
Accident Review for past 3 years:
Date
City, State
# Fatalities
# Injuries
Nature of Accident (Head-on, Rear-end, etc.)
(List none or NA if clean record)
Motor Vehicle Laws & Ordinances for the past 3 years other than parking violation:
Location
Date
Charge
Penalty
(List none or NA if clean record)
EXPERIENCE
Class of Equipment
Type (Van, Tank, Etc.)
Dates (From)
(To)
Applicant: Read and sign before submitting this application.
It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty and reason for non-consideration or subsequent dismissal if hired or denial of authorization to drive. It is also agreed and understood that the motor carrier and his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his/her furnishing such information.
I authorize the motor carrier to access the FMCSA Pre-Employment Screening Program (PSP) 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 that nothing contained in this application or in the granting of any interview or a road test is intended to create an employment contract between this company and myself, for either employment, authorization to drive, or for the providing of any benefits. I agree to furnish such additional information that may be necessary and complete such examinations as may be required to complete my application file including but not limited to a pre-employment negative urine test and successful completion of a human performance evaluation including a Department of Transportation Physical. No promises regarding employment or authorization to drive have been made to me, and no such promises exist unless specifically made by this Company in writing. It is agreed and understood that if qualified, hired, or contract started, I may be on a probationary period during which time I may be disqualified without recourse. I understand employment or authorization to drive with this carrier is on an “at-will” basis that allows me to quit, be fired, or lease agreement revoked at any time with or without notice and with or without cause. 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.
Applicant’s Printed Name
Applicant Signature
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Date
MM slash DD slash YYYY
DISCLOSURE STATEMENT
Applicant: Read and sign before submitting this application.
By this document,
Motor Carrier Name
discloses to you that a consumer report, including an investigative report containing information as to your character, general reputation, personal characteristics, driving record, and mode of living may be obtained as part of a background investigation as part of the
Motor Carrier Name's
driver qualification process. Should an investigation consumer report be requested you have the right to demand a complete and accurate disclosure of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act. Please sign below to signify receipt of the foregoing disclosure.
Applicant Signature
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Applicant’s Printed Name
Date
MM slash DD slash YYYY
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OFFICE USE ONLY
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Hire Date
MM slash DD slash YYYY
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Employment Denial Date:
MM slash DD slash YYYY
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Staff Initials: