Driver application - Drake Farms Trucking

Date*

Position applying for; Select all applying for:

Contractor Driver Contractor's driver

First name*

Middle name

Last name*

Email address:

Phone number:*

Emergency Phone number:

Date of birth: format= MM/DD/YYYY

Resume upload

Age:

SSN: format= ###-##-###

Physical Exam Expiration Date:

Current address: #1*

Dates: #1

Three years of previous addresses: #2

Dates: #2

Three years of previous addresses: #3

Dates: #3

Three years of previous addresses: #4

Dates: #4

Have you worked for this company previously?*

YesNo

If yes, give dates: Start date

If yes, give dates: End date

Reason for leaving

Education History: Please select the highest grade completed.

Employment history: Give a complete record of all employment for the past three years, including any unemployment os self employment, and all commercial driving experience for the past ten years.

Month/Year From:

Month/Year To:

Current employer name/company name:

Address

Position held

Phone number

Reason for leaving

Were you subject to the FMCSRs* while employed here?

YesNo

Was your job designed as a sefety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirments of 49 CFR Part 40?

Yes
No

Month/Year From:

Month/Year To:

Employer name/company name:

Address

Position held

Phone number

Reason for leaving

Were you subject to the FMCSRs* while employed here?

YesNo

Was your job designed as a sefety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirments of 49 CFR Part 40?

Yes
No

Month/Year From:

Month/Year To:

Employer name/company name:

Address

Position held

Phone number

Reason for leaving

Were you subject to the FMCSRs* while employed here?

YesNo

Was your job designed as a sefety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirments of 49 CFR Part 40?

Yes
No

Month/Year From:

Month/Year To:

Employer name/company name:

Address

Position held

Phone number

Reason for leaving

Were you subject to the FMCSRs* while employed here?

YesNo

Was your job designed as a sefety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirments of 49 CFR Part 40?

Yes
No

Month/Year From:

Month/Year To:

Employer name/company name:

Address

Position held

Phone number

Reason for leaving

Were you subject to the FMCSRs* while employed here?

YesNo

Was your job designed as a sefety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirments of 49 CFR Part 40?

Yes
No

*The federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who aperates a motor vehicle on a highway in interstate commerce to transport passengers or property when vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.

Driving Experience:

Date

Date to:

Driving Experience:

Date

Date to:

Driving Experience:

Date

Date to:

Driving Experience:

Date

Date to:

Driving Experience:

Date

Date to:

List states operated in, for the last five years:

List special courses/training completed (PTD/DDC, Haz Mat, Tec.)

List any Safe Driving Awards you hold and from whom:

Accident Record for the past three years:

Date of accident:

Nature of accident: (Head on, rear end, upset, etc.)

Location of accident

# of Fatalities

# of people injured

Date of accident:

Nature of accident: (Head on, rear end, upset, etc.)

Location of accident

# of Fatalities

# of people injured

Date of accident:

Nature of accident: (Head on, rear end, upset, etc.)

Location of accident

# of Fatalities

# of people injured

Date of accident:

Nature of accident: (Head on, rear end, upset, etc.)

Location of accident

# of Fatalities

# of people injured

Any additional accidents not listed above?

YesNo

Traffic Convistions andForfeiture for the last three years (other than parking violations)

Date:

Location:

Charge

Penalty

Date:

Location:

Charge

Penalty

Date:

Location:

Charge

Penalty

Driver's License (list each driver's license held in the past three years)

State:

License #

Type

Endorsements

Expiration date:

State:

License #

Type

Endorsements

Expiration date:

State:

License #

Type

Endorsements

Expiration date:

State:

License #

Type

Endorsements

Expiration date:

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

Yes
No

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

Yes
No

C. Is there any reason you might be unable to perform the functions of the job for which you are applied (as descripbed in the job description)?*

Yes
No

D. Have you ever been convisted or a felony*?*

Yes
No

If the answers to A, B, C or D is "YES", provide details:

*Disclosure of this information does not automatically exclude the driver from consideration.

To be Read and Signed by driver:*

It is agreed and understood that any misrepresentation given on this document shal be considered an act of dishonesty,
It is agreed and understood that the motor carrier or his agents may investigate my background to ascertain any and all information of concern to commercial driving record, whether same is of record or not, And I release the employers and persons named herein from all lialibilty for any damages on account of their furnishing such information.
It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigation an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

This certifies that the above information was completed by me, and that all entries on it andinformation in it are true and complete to the best of my knowledge.

I agree