Employment Application | FORM – Executive Coach Safety

Who is this from?

Hidden

Simple Company Name

Executive Coach, Inc.

Title for E-signature sections

I would like to apply for a position with:

Executive Coach, Inc., 525 Beaver Valley Pike Lancaster, PA 17602-1601 TEL | 844-924-8755 FAX | 717 464-4033

Hidden

Respond to:

FAX: (717) 464-4033 EMAIL: admin@executive.tssos1.com

Hidden

Welcome!

Thank you for your interest in employment. To apply for any position, please complete our online application for employment. Incomplete information will delay the processing of your application or prevent it from being submitted. In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

Helpful Hints

Required entry fields are followed by * meaning you must provide the requested information to continue. If you encounter any errors during this process and cannot continue, please contact us using the Contact Admin option.

Applicant Information

Today's Date*

Name*

First Middle Last

Preferred First Name

First

Email*

Enter Email Confirm Email

Please upload a resume or cover letter

Drop files here or

Max. file size: 20 MB.

Although resume is not required, we strongly encourage candidates to attach resume if available.

Are you applying for a Commercial Driving Job and have a Current CDL?*

Yes
No

In order to successfully apply for this employer, you must verify that you meet the qualifications. Please review the Qualifications listed below and identify you have the information and meet the requirements.

To complete this application, you will need to confirm you have the following items:*

Social Security Number

Home address history for past 3 years

Current driver's license number and driver's license history for the past 5 years

Employment history up to 10 years - Last 3 years of Employment History and the previous 10 years if Commercial Driving was performed

History of traffic accidents, violations and/or convictions from the last 5 years (including DUI or reckless driving conviction and license suspension)

Military history (if applicable and within the past 5 years)

I confirm I have these items and information

Please confirm that you meet these requirements:*

Must be at least 22 years of age with 2 years OTR verifiable applicable drive experience within the past 3 years.

Must not have more than 3 moving violations within the previous 3 years.

Must not have a DWI, DUI, or Reckless driving conviction within the past five (5) years.

Must have a valid CDL, Class B or greater with passenger endorsement.

Must be able to read, write and speak English.

I meet the requirements listed

1. Personal Information

Name

First Middle Last

SSN / SID*

Date of Birth*

(The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.) This field is mandatory as related to the Criminal Background Check

Primary Phone*

If your cell phone is also your primary phone, enter it in both fields.

Cell Phone*

If your cell phone is also your primary phone, enter it in both fields.

Current Address

Current Address*

Street Address County City State / Province / Region ZIP / Postal Code Country

1. Date From*

1. Date To*

1. Years at Current Address

1. Does this cover your last three years of residence?

Yes it does
No, I need to add an additional residence.

Second Address

2. Second Address*

Street Address County City State / Province / Region ZIP / Postal Code Country

2. Date From*

2. Date To*

2. Years at This Address

2. Does this cover your last three years of residence?

Yes it does
No, I need to add an additional residence.

Third Address

3. Third Address*

Street Address County City State / Province / Region ZIP / Postal Code Country

3. Date From*

3. Date To*

3. Years at This Address

3. Does this cover your last three years of residence?

Yes it does
No, I need to add an additional residence.

Fourth Address

4. Fourth Address*

Street Address County City State / Province / Region ZIP / Postal Code Country

4. Date From*

4. Date To*

4. Years at This Address

Residence History

Hidden

Hidden Calculation field for total years of residence

This field would not populate e-siganture field properly with caculations, copy-cat to 587

Total years for Residence History

YOU MUST PROVIDE 3 Years or more years or residential history before progressing!!

2. Emergency Contact Information

Emergency Contact Name*

Name

Emergency Contact Relationship*

Emergency Contact Primary Telephone*

If the cell phone is also the primary phone, enter it in both fields.

Emergency Contact Secondary Telephone

If the cell phone is also the primary phone, enter it in both fields.

3. Employment Type Desired

Full time or Part Time Desired?*

Full Time
Part Time

Whom were you referred by?

Name

Have you worked for this Company Before?*

Yes
No

If you have worked for this company before, why did you leave?*

Better Opportunity
Terminated or Laid Off
Adventure

Date of employment From*

Date of employment To*

How will you get to work?*

Personal Vehicle
Ride Share Transportation
Public Transportation

Are you willing to work any shift, including nights and weekends?*

Yes
No

Please explain any limitations.

If applicable, are you willing to work overtime?*

Yes
No

If you are offered employment, when would you be available to begin work?*

Are you able to perform the essential function of the job position you seek with or without reasonable accommodation?*

Yes
No

What reasonable accommodation, if any, would you request?

4. Salary Desired

Salary Desired:*

Compensation Unit*

Hourly
Monthly
Annually

If hired, are you able to submit proof that you are legally eligible for employment in the United States?*

Yes
No

5. Criminal History

Do you live in a State that prohibits an employer asking about your criminal history?*

Yes
No
I am unsure

Have you ever been convicted of a Crime?*

Yes
No

Please Explain*

THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.

6. Applicant's Education and Training

Educational Experience*

High School Graduate or GED
Some College
College Degree
Post College Degree
Technical (graduate, technical, vocational)

Last School Attended*

Did you receive a degree?*

Yes
No

Degree type received:*

Would you like to provide the school address?*

Yes
No

School Address

Street Address City State / Province / Region ZIP / Postal Code Country

List any professional licenses or certifications that you hold:

Please indicate any Awards, Honors or Special Achievements

6.1 Administrative Skills and Training

Skill Type*

Select All
Microsoft Office Suite (Word, Excel, Powerpoint)
Typing, Keyboarding, Filing
Accounting, Bookkeeping, Reconciliation, Auditing
Telephones, VOIP Phones, Cellular Asset Management
Customer Service, Sales, CRM
Web Sites, HTML, CSS, WordPress
Other

Microsoft Office Suite (Word, Excel, Powerpoint)*

Basic Knowledge - Experience
Advanced Knowledge - Experience
Superior Knowledge - Experience

Typing, Keyboarding, Filing*

Basic Knowledge - Experience
Advanced Knowledge - Experience
Superior Knowledge - Experience

Accounting, Bookkeeping, Reconciliation, Auditing*

Basic Knowledge - Experience
Advanced Knowledge - Experience
Superior Knowledge - Experience

Telephones, VOIP Phones, Cellular Asset Management*

Basic Knowledge - Experience
Advanced Knowledge - Experience
Superior Knowledge - Experience

Customer Service, Sales, CRM*

Basic Knowledge - Experience
Advanced Knowledge - Experience
Superior Knowledge - Experience

Web Sites, HTML, CSS, WordPress*

Basic Knowledge - Experience
Advanced Knowledge - Experience
Superior Knowledge - Experience

Please describe OTHER

7. Military Service

Are you or were you a member of the Military?*

Yes
No

Military Branch Served*

Please list any specialized Training and Discharge Status:*

Date from*

Date to*

If you are still active, please enter today's date.

Are you currently enlisted, in the reserves or otherwise still engaged with the military services?*

Yes
No

8. License Driving Record

Do you have a CDL (commercial driver's license)?*

Yes
No

How many years have you had your CDL?

DRIVER APPLICANTS: Please list all states you have been licensed in within the last FIVE years. Is the license you are listing below the only License you have held within the last five years?*

Yes
No

Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify I do not have more than one motor vehicle license, the information for which is listed here.

Current Driver's License Number*

If you do not possess a Driver License, Please write "None"

Current License Class*

If you do not possess a Driver License, Please write "None"

Current State of Issue*

If you do not possess a Driver License, Please select the state you were born in.

Drivers License Expiration Date*

If you do not possess a Driver License, Please select today's date.

DOL Eye Color Listed on your License:*

If you do not possess a Driver License, Please type in your eye color.

Endrosements*

Passenger
School Bus
Hazardous Materials
Tankers
Doubles/Triples
None

DRIVER APPLICANTS: Please list all states you have been licensed in within the last FIVE years. Does license you are listing below complete the licenses you have held in the last five years?*

Yes
No

Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify I do not have more than one motor vehicle license, the information for which is listed here.

Driver License Number*

State of Issue*

State / Province / Region

Expiration Date*

Date of Birth*

Gender on license*

Male
Female

Hair Color on License:*

It is not required, however it makes it much easier to process your application if you upload the requested copy of your License at this time.*

I will upload a copy of my license at this time
I will provide a copy of my license at a later time

Please Upload an image of the FRONT of your Driver's License

Drop files here or

Max. file size: 20 MB.

Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify I do not have more than one motor vehicle license, the information for which is listed below.*

I hereby certify this is the only Driver's License that I posess

9. Ethnicity and Race

Privacy Act Statement*

Ethnicity and race information is requested under the authority of 42 U.S.C. Section 2000e-16 and in compliance with the Office of Management and Budget's 1997 Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity. Providing this information is voluntary and has no impact on your employment status, but in the instance
of missing information, your employing agency will attempt to identify your race and ethnicity by visual observation.

This information is used as necessary to plan for equal employment opportunity throughout the Federal government. It is also used by the U. S. Office of Personnel Management or employing agency maintaining the records to locate individuals for personnel research or survey response and in the production of summary descriptive statistics and analytical studies in support of the function for which the records are collected and maintained, or for related workforce studies.

Social Security Number (SSN) is requested under the authority of Executive Order 9397, which requires SSN be used for the purpose of uniform, orderly administration of personnel records. Providing this information is voluntary and failure to do so will have no effect on your employment status. If SSN is not provided, however, other agency sources may be used to obtain it.

I understand this Privacy Act Statement

Question 1. Are You Hispanic or Latino?*

Yes
No
Withheld

(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

Question 2. Please select the racial category or categories with which you most closely identify.*

Please select the racial category or categories with which you most closely identify.

Height*

This is used for the Criminal Back Ground Check form that will be populated automatically for you when you submit this form. This is not required, however as a courtesy, this response will automatically fill in the required information on another required document that is allowed to be requested. If you choose not to answer this question, we will have to request additional information at a later date, which will slow down the process of your employment application.

Weight*

This is used for the Criminal Back Ground Check form that will be populated automatically for you when you submit this form. This is not required, however as a courtesy, this response will automatically fill in the required information on another required document that is allowed to be requested. If you choose not to answer this question, we will have to request additional information at a later date, which will slow down the process of your employment application.

10. Previous Employment

Drivers Applying to operate commercial vehicles*

List your current or most recent employer first.

Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment.

If additional fields are needed, please explain this in the comments field.

Please provide ten years employment history if you have it.

Please provide ten years history including school if necessary.

For those drivers applying to operate a commercial motor vehicle as defined by part 383 of this subchapter, a list of the names and addresses of the applicant's employers during the 7-year period preceding the 3 years contained in paragraph (b)(10) of this section for which the applicant was an operator of a commercial motor vehicle, together with the dates of employment and the reasons for leaving such employment must be provided.

I will provide the ten year history as required

Most Recent Employer

First Company Name*

Company Name

DRIVER Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*

1. Beginning Date of Employment*

1. Ending Date of Employment*

If you are still employed, please select today's date.

1. Duration of Employment

1. Do you intend to remain employed with this employer?*

Yes
No

1. Were you subject to the FMCSRs while employed by this previous employer?*

Yes
No

Were you subject to the FMCSRs while employed by this previous employer?

1. Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?*

Yes
No

Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

1. Supervisor Name*

Name

1. We will need to contact your previous employer. You must provide either a FAX number or a valid email address. Which would you like to provide?*

FAX Number
Email Address
Both

1. Company Phone*

1. Company FAX*

1. Supervisor or HR Email*

Enter Email Confirm Email

1. Company Address*

Street Address City State ZIP Code

1. Job Duties*

1. Reason for leaving*

1. Do you live in a State that prohibits asking what your previous rate of pay was?*

Yes
No
I do no know

1. Rate of pay (per hour)*

1. Does this complete your ten year commercial vehicle driving/employment history?*

Yes, this completes my ten year history
No, I need to add information

Please make sure to include any gaps in employment, school, military, sabbatical, extended vacations or other gaps in employment. If you do not have a CDL, please answer this question yes.

Second Employer

2. Company Name*

Company Name

DRIVER Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*

2. Beginning Date of Employment*

2. Ending Date of Employment*

If you are still employed, please select today's date.

2. Duration of Employment

2. Were you subject to the FMCSRs while employed by this previous employer?*

Yes
No

Were you subject to the FMCSRs while employed by this previous employer?

2. Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?*

Yes
No

Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

2. Supervisor Name*

Name

2. We will need to contact your previous employer. You must provide either a FAX number or a valid email address. Which would you like to provide?*

FAX Number
Email Address
Both

2. Company Phone*

2. Company FAX*

2. Supervisor or HR Email*

Enter Email Confirm Email

2. Company Address*

Street Address City State ZIP Code

2. Job Duties*

2. Reason for leaving*

2. Do you live in a State that prohibits asking what your previous rate of pay was?*

Yes
No
I do no know

2. Rate of pay (per hour)*

2. Does this complete your ten year commercial vehicle driving/employment history?*

Yes, this completes my ten year history
No, I need to add information

Please make sure to include any gaps in employment, school, military, sabbatical, extended vacations or other gaps in employment. If you do not have a CDL, please answer this question yes.

Third Employer

3. Company Name*

Company Name

DRIVER Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*

3. Beginning Date of Employment*

3. Ending Date of Employment*

If you are still employed, please select today's date.

3. Duration of Employment

3. Were you subject to the FMCSRs while employed by this previous employer?*

Yes
No

Were you subject to the FMCSRs while employed by this previous employer?

3. Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?*

Yes
No

Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

3. Supervisor Name*

Name

3. We will need to contact your previous employer. You must provide either a FAX number or a valid email address. Which would you like to provide?*

FAX Number
Email Address
Both

3. Company Phone*

3. Company FAX*

3. Supervisor or HR Email*

Enter Email Confirm Email

3. Company Address*

Street Address City State ZIP Code

3. Job Duties*

3. Reason for leaving*

3. Do you live in a State that prohibits asking what your previous rate of pay was?*

Yes
No
I do no know

3. Rate of pay (per hour)*

3. Does this complete your ten year commercial vehicle driving/employment history?*

Yes, this completes my ten year history
No, I need to add information

Please make sure to include any gaps in employment, school, military, sabbatical, extended vacations or other gaps in employment. If you do not have a CDL, please answer this question yes.

Fourth Employer

4. Company Name*

Company Name

DRIVER APPLICANTS ONLY: that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*

4. Beginning Date of Employment*

4. Ending Date of Employment*

If you are still employed, please select today's date.

4. Duration of Employment

4. Were you subject to the FMCSRs while employed by this previous employer?*

Yes
No

Were you subject to the FMCSRs while employed by this previous employer?

4. Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?*

Yes
No

Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

4. Supervisor Name*

Name

4. We will need to contact your previous employer. You must provide either a FAX number or a valid email address. Which would you like to provide?*

FAX Number
Email Address
Both

4. Company Phone*

4. Company FAX*

4. Supervisor or HR Email*

Enter Email Confirm Email

4. Company Address*

Street Address City State ZIP Code

4. Job Duties*

4. Reason for leaving*

4. Do you live in a State that prohibits asking what your previous rate of pay was?*

Yes
No
I do no know

4. Rate of pay (per hour)*

4. Does this complete your ten year commercial vehicle driving/employment history?*

Yes, this completes my ten year history
No, I need to add information

Please make sure to include any gaps in employment, school, military, sabbatical, extended vacations or other gaps in employment. If you do not have a CDL, please answer this question yes.

Fifth Employer

5. Company Name*

Company Name

DRIVER APPLICANTS ONLY: that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*

5. Beginning Date of Employment*

5. Ending Date of Employment*

If you are still employed, please select today's date.

5. Duration of Employment

5. Were you subject to the FMCSRs while employed by this previous employer?*

Yes
No

Were you subject to the FMCSRs while employed by this previous employer?

5. Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?*

Yes
No

Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

5. Supervisor Name*

Name

5. We will need to contact your previous employer. You must provide either a FAX number or a valid email address. Which would you like to provide?*

FAX Number
Email Address
Both

5. Company Phone*

5. Company FAX*

5. Supervisor or HR Email*

Enter Email Confirm Email

5. Company Address*

Street Address City State ZIP Code

5. Job Duties*

5. Reason for leaving*

5. Do you live in a State that prohibits asking what your previous rate of pay was?*

Yes
No
I do no know

5. Rate of pay (per hour)*

5. Does this complete your ten year commercial vehicle driving/employment history?*

Yes, this completes my ten year history
No, I need to add information

Please make sure to include any gaps in employment, school, military, sabbatical, extended vacations or other gaps in employment. If you do not have a CDL, please answer this question yes.

Sixth Employer

6. Company Name*

Company Name

DRIVER APPLICANTS ONLY: that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*

6. Beginning Date of Employment*

6. Ending Date of Employment*

If you are still employed, please select today's date.

6. Duration of Employment

6. Were you subject to the FMCSRs while employed by this previous employer?*

Yes
No

Were you subject to the FMCSRs while employed by this previous employer?

6. Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?*

Yes
No

Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

6. Supervisor Name*

Name

6. We will need to contact your previous employer. You must provide either a FAX number or a valid email address. Which would you like to provide?*

FAX Number
Email Address
Both

6. Company Phone*

6. Company FAX*

6. Supervisor or HR Email*

Enter Email Confirm Email

6. Company Address*

Street Address City State ZIP Code

6. Job Duties*

6. Reason for leaving*

6. Do you live in a State that prohibits asking what your previous rate of pay was?*

Yes
No
I do no know

6. Rate of pay (per hour)*

6. Does this complete your ten year commercial vehicle driving/employment history?*

Yes, this completes my ten year history
No, I need to add information

Please make sure to include any gaps in employment, school, military, sabbatical, extended vacations or other gaps in employment. If you do not have a CDL, please answer this question yes.

Seventh Employer

7. Company Name*

Company Name

DRIVER APPLICANTS ONLY: that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*

7. Beginning Date of Employment*

7. Ending Date of Employment*

If you are still employed, please select today's date.

7. Duration of Employment

7. Were you subject to the FMCSRs while employed by this previous employer?*

Yes
No

Were you subject to the FMCSRs while employed by this previous employer?

7. Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?*

Yes
No

Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

7. Supervisor Name*

Name

7. We will need to contact your previous employer. You must provide either a FAX number or a valid email address. Which would you like to provide?*

FAX Number
Email Address
Both

7. Company Phone*

7. Company FAX*

7. Supervisor or HR Email*

Enter Email Confirm Email

7. Company Address*

Street Address City State ZIP Code

7. Job Duties*

7. Reason for leaving*

7. Do you live in a State that prohibits asking what your previous rate of pay was?*

Yes
No
I do no know

7. Rate of pay (per hour)*

7. Does this complete your ten year commercial vehicle driving/employment history?*

Yes, this completes my ten year history
No, I need to add information

Please make sure to include any gaps in employment, school, military, sabbatical, extended vacations or other gaps in employment. If you do not have a CDL, please answer this question yes.

Eighth Employer

8. Company Name*

Company Name

DRIVER APPLICANTS ONLY: that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*

8. Beginning Date of Employment*

8. Ending Date of Employment*

If you are still employed, please select today's date.

8. Duration of Employment

8. Were you subject to the FMCSRs while employed by this previous employer?*

Yes
No

Were you subject to the FMCSRs while employed by this previous employer?

8. Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?*

Yes
No

Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

8. Supervisor Name*

Name

8. We will need to contact your previous employer. You must provide either a FAX number or a valid email address. Which would you like to provide?*

FAX Number
Email Address
Both

8. Company Phone*

8. Company FAX*

8. Supervisor or HR Email*

Enter Email Confirm Email

8. Company Address*

Street Address City State ZIP Code

8. Job Duties*

8. Reason for leaving*

8. Do you live in a State that prohibits asking what your previous rate of pay was?*

Yes
No
I do no know

8. Rate of pay (per hour)*

8. Does this complete your ten year commercial vehicle driving/employment history?*

Yes, this completes my ten year history
No, I need to add information

Please make sure to include any gaps in employment, school, military, sabbatical, extended vacations or other gaps in employment. If you do not have a CDL, please answer this question yes.

Ninth Employer

9. Company Name*

Company Name

DRIVER APPLICANTS ONLY: that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*

9. Beginning Date of Employment*

9. Ending Date of Employment*

If you are still employed, please select today's date.

9. Duration of Employment

9. Were you subject to the FMCSRs while employed by this previous employer?*

Yes
No

Were you subject to the FMCSRs while employed by this previous employer?

9. Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?*

Yes
No

Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

9. Supervisor Name*

Name

9. We will need to contact your previous employer. You must provide either a FAX number or a valid email address. Which would you like to provide?*

FAX Number
Email Address
Both

9. Company Phone*

9. Company FAX*

9. Supervisor or HR Email*

Enter Email Confirm Email

9. Company Address*

Street Address City State ZIP Code

9. Job Duties*

9. Reason for leaving*

9. Do you live in a State that prohibits asking what your previous rate of pay was?*

Yes
No
I do no know

9. Rate of pay (per hour)*

9. Does this complete your ten year commercial vehicle driving/employment history?*

Yes, this completes my ten year history
No, I need to add information

Please make sure to include any gaps in employment, school, military, sabbatical, extended vacations or other gaps in employment. If you do not have a CDL, please answer this question yes.

Tenth Employer

10. Company Name*

Company Name

DRIVER APPLICANTS ONLY: that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*

10. Beginning Date of Employment*

10. Ending Date of Employment*

If you are still employed, please select today's date.

10. Duration of Employment

10. Were you subject to the FMCSRs while employed by this previous employer?*

Yes
No

Were you subject to the FMCSRs while employed by this previous employer?

10. Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?*

Yes
No

Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

10. Supervisor Name*

Name

10. We will need to contact your previous employer. You must provide either a FAX number or a valid email address. Which would you like to provide?*

FAX Number
Email Address
Both

10. Company Phone*

10. Company FAX*

10. Supervisor or HR Email*

Enter Email Confirm Email

10. Company Address*

Street Address City State ZIP Code

10. Job Duties*

10. Reason for leaving*

10. Do you live in a State that prohibits asking what your previous rate of pay was?*

Yes
No
I do no know

10. Rate of pay (per hour)*

Employment Confirmation

Hidden

Hidden calculation field for years of employment

Calculates totl years of employment and populates field below via Copy-cat

Total years employment history provided

Commercial Driver Applicants must provide ten years of CMV employment history.

Did you drive any commercial vehicles for any company in the last ten years that you were unable to list above?

Yes
No

WARNING!!!!! You may need to provide additional information, please make proper notes in field provided to identify issues. Failure to do so could equate to falsification of the application.

Please provide any other information that you believe needs to be considered.

11. References

List any two non-relatives who would be willing to provide reference for you.

Name*

Name

Phone*

Address

Street Address City State ZIP Code

Relationship*

Previous employer
Land Lord
Friend

Name*

Name

Phone*

Address

Street Address City State ZIP Code

Relationship*

Previous employer
Land Lord
Friend

12. Driving Experience

What Types of CMV have you experience Operating?*

Motor Coach
Mini Coach
Straight Truck
Dump Truck
Semi-Trailers
Semi Doubles/Triples
Semi Tankers or HAZMAT
Flatbed
Other

Motorcoach

Date From	Date To	Approx. Miles

Minicoach

Date From	Date To	Approx. Miles

Straight truck

Date From	Date To	Approx. Miles

Dump truck

Date From	Date To	Approx. Miles

Semi-Trailers

Date From	Date To	Approx. Miles

Semi-Doubles/Triples

Date From	Date To	Approx. Miles

Semi-Tankers or HAZMAT

Date From	Date To	Approx. Miles

Semi-Flatbed

Date From	Date To	Approx. Miles

Other Equipment Type

Describe Equipment	Date From	Date To	Approx. Miles

Accident and Collision History

How Many Accidents have you had in last the three years?*

Please enter all Accidents within the last three years, including any fixed object strikes, wehter they were your responsibility or not, preceding the date of application. These will be verified with your Motor Vehicle Record, previous employer request as well as the PSP Report. If you have NONE, please select None.

First Accident

1. Nature of Accident*

Rear ended
Side Swipe
Rollover

Date of Occurrence*

Were Fatalities or Personal Injuries Sustained?*

Yes
No

Was this a Reportable DOT Accident?*

Yes
No

Second Accident

2. Nature of Accident*

Rear ended
Side Swipe
Rollover

Date of Occurrence*

Were Fatalities or Personal Injuries Sustained?*

Yes
No

Was this a Reportable DOT Accident?*

Yes
No

Third Accident

3. Nature of Accident*

Rear ended
Side Swipe
Rollover

Date of Occurrence*

Were Fatalities or Personal Injuries Sustained?*

Yes
No

Was this a Reportable DOT Accident?*

Yes
No

Fourth Accident

4. Nature of Accident*

Rear ended
Side Swipe
Rollover

Date of Occurrence*

Were Fatalities or Personal Injuries Sustained?*

Yes
No

Was this a Reportable DOT Accident?*

Yes
No

Tickets and Citations History

Please enter all Violations of motor vehicle laws or ordinances (other than violations involving only parking) of which the applicant was convicted or forfeited bond or collateral during the last three years preceding the date of application. These will be verified with your Motor Vehicle Record as well as the PSP Report. If you have NONE, please enter "NONE" as opposed to "N/A"*

None
1
2
3

Please enter all Citations within the last three years preceding the date of application. These will be verified with your Motor Vehicle Record as well as the PSP Report. If you have NONE, please select None.

First Violation

1. Nature of Violation*

Speeding
Lane Travel
Equimpment

Date of Occurrence*

Was this in a Commercial Motor Vehicle?*

Yes
No

Were Fatalities or Personal Injuries Sustained?*

Yes
No

Second Violation

2. Nature of Violation*

Speeding
Lane Travel
Equimpment

Date of Occurrence*

Was this in a Commercial Motor Vehicle?*

Yes
No

Were Fatalities or Personal Injuries Sustained?*

Yes
No

Third Violation

3. Nature of Violation*

Speeding
Lane Travel
Equimpment

Date of Occurrence*

Was this in a Commercial Motor Vehicle?*

Yes
No

Were Fatalities or Personal Injuries Sustained?*

Yes
No

Motor Vehicle Record

Do you have a current MVR (Motor Vehicle Record, Driver Abstract, Pull Sheet) that is less than 30 days old?*

Yes
No

It is not required, however it makes it much easier to process your application if you upload the requested copy of your Driving Record at this time.*

I will upload a copy of my Driving Record at this time
I will provide a copy of my Driving Record at a later time

COMPLETE Driving Record

Drop files here or

Max. file size: 20 MB.

You may upload your COMPLETE Motor Vehicle Driving Record that is less than 30 Days Old here. You will be required to provide a copy of the Driving Record before you are hired. If you live in the state of Washington, you may obtain this document here: http://www.dol.wa.gov/driverslicense/requestyourrecord.html

Medical Certificate

Do you currently have a valid medical card?*

Yes
No

Medical Certificate Expiration Date*

It is not required, however it makes it much easier to process your application if you upload the requested copy of your Medical Examiner Card at this time.*

I will upload a copy of my Medical Examiner Card at this time
I will provide a copy of my Medical Examiner Card at a later time

Please upload a FRONT image of your CURRENT Medical Examiners Card

Drop files here or

Max. file size: 20 MB.

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

Yes
No

Please Explain*

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

Yes
No

Please Explain*

Drug and Alcohol History

Have you ever tested positive on a drug or alcohol test?*

Yes
No

Please Explain*

49 CFR 40.25(j) -During the past three (3) years have you tested positive on a pre-employment alcohol or drug test administered by Employer to which you applied for but did not obtain. a safety sensitive transportation work covered by Department of Transportation (DOT) drug and alcohol testing rules?*

Yes
No

If you answered yes to the above question, have you successfully completed the return-to-duty process?*

Yes
No

If yes, you must provide documentation before any Safety-sensitive transportation function is performed. How will you deliver this information?*

During the past three (3) years have you refused to test on a Pre-employment alcohol or drug test administered by an Employer to which you applied for but did not obtain a safety sensitive transportation work covered by the Department of Transportation (DOT) drug and alcohol testing roles?*

Yes
No

Please Explain*

In the past three (3) years, have you ever been convicted of any of the following offenses committed during on-duty time [49 C.F.R. 391.15 and 49 C.F.R. 395.2]:*

Driving a commercial motor vehicle with a blood alcohol concentration ("BAC") of .04 percent or more
Driving under the influence of alcohol, as prescribed by state law
Refusal to undergo drug and alcohol testing as required by any jurisdiction for the enforcement of Federal Motor Carrier Safety Act regulations
Driving a commercial motor vehicle under the influence of any 21 C.F.R. 1308.11 Schedule I identified controlled substance, an amphetamine, a narcotic drug, a formulation of an amphetamine, or a derivative of a narcotic drug
Transportation, possession, or unlawful use of a 21 C.F.R. 1308.11 Schedule I identified controlled substance, amphetamines, narcotic drugs, formulations of an amphetamine, or derivatives of narcotic drugs while you were on duty driving for a motor carrier
Leaving the scene of an accident while operating a commercial motor vehicle
Or any other felony involving the use of a commercial motor vehicle

I have not been convicted of any of these within the last three years

All driver applicants will be required to submit to and pass a drug and alcohol test as a condition of employment. Job applicants who are denied employment because of a positive test may reapply for employment after 6 months. Offers of employment are made upon passing the Company's review, including the drug and alcohol test. Driver applicants who have received firm employment offers should be cautioned against giving notice to their current place of employment until after medical clearance has been received. In compliance with DOT regulations, your name will be added to the Random Selection Program for drug and alcohol testing for continued employment.*

I understand and agree to these terms and conditions

13. Review and acknowledge the following information

Former Employer and Educational Contact*

I authorize the company or representative of the company listed on this application to contact former employers and educational organizations regarding my employment and education.

I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades.

I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

I authorize previous employer and school contact and requests for information

At-Will Employment Relationship*

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its CEO, the employment relationship will be "at-will."

In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause.

With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice.

Similarly, my employer will have the right.

Moreover, no agent, representative, or employee of the company or representative of the company listed on this application, except in a specific written contract of employment signed on behalf of the organization by its CEO, has the power to alter or vary the voluntary nature of the employment relationship.

I understand employment is At-Will

Medical Examinations*

The Company may not require a pre-employment medical examination but does reserve the right to require drug testing and a medical examination after an offer of employment is made to the applicant.

All offers of employment are conditional upon the passing of a drug test for the purpose of detecting the illegal use of drugs.

Also, if an employment offer is made, you will be asked to answer certain medical questions.

Medical examinations and answers to medical inquiries will be maintained on separate forms and will be treated as confidential medical records.

An applicant will not be excluded from employment unless they have medical conditions that prohibit their ability to perform the essential job functions of the position they desire within this company.

The Company will make reasonable accommodations to qualified individuals with disabilities in the application process and, if hired, allow qualified individuals with disabilities to perform essential job functions.

Written job descriptions are available and will be furnished to applicants upon request.

The Company may use the information contained in this application and may contact your former employer(s) for the purpose of investigating your safety performance history information as required by the Federal Motor Safety Regulations (49 CFR 391.23 (d) and (3).

Pursuant to 49 CFR 391.23 (i), you have the following rights regarding the investigative information that is provided to The Company by your previous employer(s):

You have the right to review the information provided by your previous employer(s);

You have the right to have errors in the information corrected by your previous employer(s) and for the previous employer(s) to re-send the corrected information to The Company; and

You have the right to have a rebuttal statement attached to the alleged erroneous information if you and your previous employer cannot agree on the accuracy of the information.

I understand and agree to the Medical Examinations Terms and Conditions

DOT DRUG AND ALCOHOL RELEASE*

DOT DRUG AND ALCOHOL RELEASE

In accordance with DOT Regulation 49 CFR Part 391.23, I authorize the release of information from my DOT regulated drug and alcohol testing records by the carriers (company/school) listed above for the sole purpose of transmitting such records to the authorized company HR or Compliance representative.

I authorize the release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years:
(i) alcohol tests with a result of 0.04 or higher;
(ii) verified positive drug tests;
(iii) refusals to be tested (including verified adulterated or substituted results);
(iv) other violations of DOT drug and alcohol testing regulations;
(v) information obtained from previous employers of a drug and alcohol rule violation(s);
and (vi) documents, if any, of completion of a return-to-duty process following a rule violation.

The information that I have authorized the appropriate company representative to review involves tests required by DOT. If any carrier (company/school) listed above furnishes information concerning items (i) through (vi) above, I also authorize that carrier (company/school) to release and furnish the dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the three-year period and the name and phone number of any substance abuse professional who evaluated me during the past three years.

I hereby authorize, without liability, any person or organization whose name I have given as reference, or by whom I have been previously employed to furnish the appropriate company representative, any information they may have concerning my character, ability, financial obligation, job performance, habits, reasons for leaving my employment and I authorize release of information to companies/carriers requesting such information.

I release all persons/organizations from any claims for damages of any kind which may occur to me by reasons for furnishing such information.

I hereby authorize you to release information to the above listed company, for the purpose of investigation as required by section 391.23 of the Federal Motor Carrier Safety Regulations. In accordance with Section 391.23 we are obligated to request information from previous employers/companies of the applicant in which he/she operated a commercial motor vehicle. Please complete the information and return to us as required by Section 391.23 (g). Please return the information ASAP by the apropriaet mthod described on the email or faxed request.

I agree with the above language

IMPORTANT NOTICE OF RIGHTS REGARDING FMCSA-DOT PRE-EMPLOYMENT SCREENING PROGRAM*

Our company will use Pre-Employment Screening Program ("PSP") information in the hiring process for our commercial truck drivers. As a driver we want you to be aware of specific rights you have under the PSP.

You must provide your written consent to us before we can request information in the PSP.

We cannot share the PSP information with any third-party and only those individuals within our company involved in the hiring process may view the information.

PSP information includes DOT reportable accidents/crash information for a period of 5 years and roadside inspection information for 3 years.

We may obtain additional accident/crash information outside of the PSP. Those reports are covered by the Fair Credit Reporting Act ("FCRA") which also provides rights to you.

You have the right to dispute any information in the PSP by contacting the Federal Motor Carrier Safety Administration ("FMCSA") at:

https://dataqs.fmcsa.dot.gov. You may also contact the FMCSA at 1200 New Jersey Avenue S.E., Washington D.C., 20590, TEL (800) 832-5660, TTY (800) 877-8339.

In addition to a dispute you can contact FMCSA as noted above to obtain a copy of information regarding you in the PSP system.

Only the FMCSA is authorized to receive disputes. Neither we nor the consumer reporting agency which provides information to us can respond to a dispute. You must directly contact the FMCSA as noted above. You need to follow the instructions on the website when presenting your dispute along with any supporting documentation statements, etc. Upon receipt of the dispute FMCSA will forward the dispute via the DataQs System to the state that originated the disputed information. That state will review the dispute and respond back to FMCSA. You will be notified on the website that a response has been received. Any correction will be entered at the next data update cycle. As for reports covered by the FCRA that are outside the PSP, you can dispute those reports with the consumer reporting agency which furnished the report.

These rights apply specifically to the PSP Report. We receive other reports as part of our hiring process that contain information outside of the PSP. Those reports are governed by the FCRA which provides specific rights to you. To learn more about these rights, contact the Federal Trade Commission at: www.ftc.gov/credit. You may also report violations of the FCRA to the Office of Financial Management, Department of Transportation, Washington D.C., 20590 TEL: (202) 366-1306.

We will inform you before we take adverse action based, in whole or in part, upon the PSP report and we will provide you a copy, free of charge, of the PSP report along with a copy of your rights under the FCRA. Thereafter, if we decide to take the adverse action against you, we will notify you and, upon request, will provide you, free of charge, a copy of the PSP report and your rights under the FCRA if you have misplaced the previous copies furnished to you.

FMCSA-DOT and NICT (which operates the website for FMCSA-DOT) do not make the decision to take any adverse action and are unable to provide you with the reasons why the adverse action was taken.

You may have greater rights under state law.

You may request, upon presenting proper identification, copies of the PSP information received by us. We will respond within three (3) business days of receiving your request. These copies are free of charge to you. Our consumer reporting agency which supplies other employment reports will not have the PSP information, nor will it have access to the PSP information.

By checking this box, I acknowledge that I have read and understand the above Important Notice of Rights and also have been given the opportunity to copy/print the notice.

Fair Credit Reporting Act*

In accordance with the provisions of the Fair Credit Reporting Act (Public La 91-508) as amended by the Consumer Credit Reporting Act of 1996, I have been informed the Company will/may procure a motor vehicle report (MVR), PSP Driver Record, Criminal Background Check, FBI, State Police, Child Abuse, Social Media and reference checks, all of which are defined as a consumer report regarding my driving and background record to determine my suitability for work at the Company.

I understand that I have the rights to request, in writing, information pertaining to the nature and scope of the inquiry and a written summary of my rights under the Fair Credit Reporting Act.

I understand that I may have additional rights under applicable state and federal laws.

I hereby authorize the Company to obtain this information and release and hold harmless any person, firm, or entity that discloses such information in accordance with this authorization.

This authorization shall remain on file and shall serve as ongoing authorization for the Company to procure a motor vehicle report (MVR) and a criminal check which is defined as a consumer report at any time during my employment period.

Any copy of this authorization shall have the same authority as the original.

Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

Remedying the Effects of Identity Theft

The Fair Credit Reporting Act (FCRA) gives you specific rights when you are, or believe that you are, the victim of identity theft. Here is a brief summary of the rights designed to help you recover from identity theft.

1. You have the right to ask that nationwide consumer reporting agencies place “fraud alerts” in your file to let potential creditors and others know that you may be a victim of identity theft. A fraud alert can make it more difficult for someone to get credit in your name because it tells creditors to follow certain procedures to protect you. It also may delay your ability to obtain credit. You may place a fraud alert in your file by calling just one of the three nationwide consumer reporting agencies. As soon as that agency processes your fraud alert, it will notify the other two, which then also must place fraud alerts in your file.

Equifax: 1-800-525-6285; www.equifax.com
Experian: 1-888-397-3742; www.experian.com
TransUnion: 1-800-680-7289; www.transunion.com

An initial fraud alert stays in your file for at least one year. An extended alert stays in your file for seven years. To place either of these alerts, a consumer reporting agency will require you to provide appropriate proof of your identity, which may include your Social Security number. If you ask for an extended alert, you will have to provide an identity theft report. An identity theft report includes a copy of a report you have filed with a federal, state, or local law enforcement agency, and additional information a consumer reporting agency may require you to submit. For more detailed information about the identity theft report, visit www.consumerfinance.gov/learnmore.

2. You have the right to free copies of the information in your file (your “file disclosure”). An initial fraud alert entitles you to a copy of all the information in your file at each of the three nationwide agencies, and an extended alert entitles you to two free file disclosures in a 12-month period following the placing of the alert. These additional disclosures may help you detect signs of fraud, for example, whether fraudulent accounts have been opened in your name or whether someone has reported a change in your address. Once a year, you also have the right to a free copy of the information in your file at any consumer reporting agency, if you believe it has inaccurate information due to fraud, such as identity theft. You also have the ability to obtain additional free file disclosures under other provisions of the FCRA. See www.consumerfinance.gov/learnmore.

3. You have the right to obtain documents relating to fraudulent transactions made or accounts opened using your personal information. A creditor or other business must give you copies of applications and other business records relating to transactions and accounts that resulted from the theft of your identity, if you ask for them in writing. A business may ask you for proof of your identity, a police report, and an affidavit before giving you the documents. It may also specify an address for you to send your request. Under certain circumstances a business can refuse to provide you with these documents. See www.consumerfinance.gov/learnmore.

4. You have the right to obtain information from a debt collector. If you ask, a debt collector must provide you with certain information about the debt you believe was incurred in your name by an identity thief – like the name of the creditor and the amount of the debt.

5. If you believe information in your file results from identity theft, you have the right to ask that a consumer reporting agency block that information from your file. An identity thief may run up bills in your name and not pay them. Information about the unpaid bills may appear on your consumer report. Should you decide to ask a consumer reporting agency to block the reporting of this information, you must identify the information to block, and provide the consumer reporting agency with proof of your identity and a copy of your identity theft report. The consumer reporting agency can refuse or cancel your request for a block if, for example, you don’t provide the necessary documentation, or where the block results from an error or a material misrepresentation of fact made by you. If the agency declines or rescinds the block, it must notify you. Once a debt resulting from identity theft has been blocked, a person or business with notice of the block may not sell, transfer, or place the debt for collection.

6. You also may prevent businesses from reporting information about you to consumer reporting agencies if you believe the information is a result of identity theft. To do so, you must send your request to the address specified by the business that reports the information to the consumer reporting agency. The business will expect you to identify what information you do not want reported and to provide an identity theft report.

7. The following FCRA right applies with respect to nationwide consumer reporting agencies:

Consumers Have the Right To Obtain a Security Freeze

You have a right to place a “security freeze” on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit.

As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer's credit file. Upon seeing a fraud alert display on a consumer's credit file, a business is required to take steps to verify the consumer's identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.

A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.

To learn more about identity theft and how to deal with its consequences, visit
www.consumerfinance.gov/learnmore, or write to the Consumer Financial Protection Bureau.
You may have additional rights under state law. For more information, contact your local
consumer protection agency or your state Attorney General.

In addition to the new rights and procedures to help consumers deal with the effects of
identity theft, the FCRA has many other important consumer protections. They are described in
more detail at www.consumerfinance.gov/learnmore.

Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

a person has taken adverse action against you because of information in your credit report;
you are the victim of identity theft and place a fraud alert in your file;
your file contains inaccurate information as a result of fraud;
you are on public assistance;
you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.

You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.

Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.

You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address form the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

The following FCRA right applies with respect to nationwide consumer reporting agencies:

Consumers Have the Right To Obtain a Security Freeze

You have a right to place a “security freeze” on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit.

As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s credit file, a business is required to take steps to verify the consumer’s identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.

A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.

You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General.

I understand and Authorize

Terms of Service*

If you have any questions regarding the conditions, you should ask for an explanation or clarification from the employment interviewer. Signify your understanding and specific acceptance of each condition by your signature in the space provided at the end of the conditions.

I hereby authorize The potential employer to investigate any and all statements contained in this application.

I certify that the information provided on this application is truthful and accurate.

I further certify that the information provided for previous employment is true and correct for the last ten years.

I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I hereby consent to The potential employer conducting any checks concerning my background which are deemed necessary, advisable, or helpful by the potential employer (except contacting my current employer prior to hiring, unless permission is granted above).

I understand that if hired, I will receive a copy of The potential employer rules and regulations and The potential employer's policies including its drug/alcohol policy.

I will read and understand the rules, regulations, and policies; and I acknowledge that I will be required to abide by them. I understand that if hired, I will be required to submit to a drug test as part of this application procedure.

I hereby consent to that drug test, agree to cooperate fully with that drug test, and waive any and all objections I might otherwise have to such drug testing.

I understand that if I am offered employment, it may be contingent upon passing a medical examination. If so, I hereby consent to such medical examination, and will fully cooperate with any required examination.

I understand and agree that if this application results in employment, my employment can be terminated with or without cause and with or without notice, at any time, at the option of either the potential employer or myself.

I understand that no manager or representative of The potential employer has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing.

I certify and guarantee that all statements made on this application are true and complete to the best of my knowledge and without mental reservations.

I understand that falsification of this application may result in my not being considered for employment or, in the event I become employed by The potential employer in my dismissal, regardless of when such falsification is discovered.

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.

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.

Did you provide the required residence history?*

Yes
No

5 years residency history required.

Total years for Residence History

Did you provide the required employment history?*

Yes
No

3 years employment record with and additional seven (10 total) years for commercial driving employment.

Total years employment history provided

Commercial Driver Applicants must provide ten years of CMV employment history.

Date of application*

Signature*

It is recommended that you use web browsers Chrome, Safari or Firefox for best performance.

APPLICATION | UNIVERSAL

Company Information

Welcome!

Helpful Hints

Applicant Information

In order to successfully apply for this employer, you must verify that you meet the qualifications. Please review the Qualifications listed below and identify you have the information and meet the requirements.

1. Personal Information

Current Address

Second Address

Third Address

Fourth Address

Residence History

YOU MUST PROVIDE 3 Years or more years or residential history before progressing!!

2. Emergency Contact Information

3. Employment Type Desired

4. Salary Desired

5. Criminal History

THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.

6. Applicant's Education and Training

6.1 Administrative Skills and Training

7. Military Service

8. License Driving Record

9. Ethnicity and Race

10. Previous Employment

Most Recent Employer

Second Employer

Third Employer

Fourth Employer

Fifth Employer

Sixth Employer

Seventh Employer

Eighth Employer

Ninth Employer

Tenth Employer

Employment Confirmation

WARNING!!!!! You may need to provide additional information, please make proper notes in field provided to identify issues. Failure to do so could equate to falsification of the application.

11. References

12. Driving Experience

Accident and Collision History

First Accident

Second Accident

Third Accident

Fourth Accident

Tickets and Citations History

First Violation

Second Violation

Third Violation

Motor Vehicle Record

Medical Certificate

Drug and Alcohol History

13. Review and acknowledge the following information

Having Problems? Contact System Admin