DRIVER APPLICATION FOR CONTRACT
Company
Address
City State Zip
(answer all questions- please print)
In accordance 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, or non-job related disability.
Position(s) Applied for
Last Name First Name MI
Social Security Number
List your addresses of residency for the past 3 years.Current Address
Street City State Zip
Phone How Long?
Previous Address
Street City State Zip
Phone How Long?
Street City State Zip
Phone How Long?
Street City State Zip
Phone How Long?
Do you have the legal right to work in the United States?
Date of Birth: Can you provide proof of age? YES NO
Have you worked for this company before? YES NO Where?
Dates: From: To: Salary: Position:
Reason for leaving
Are you now employed? If not, how long since leaving last employment?
Who referred you? Rate of pay expected
Is there any reason you might be unable to perform the functions of the job for which you have applied?
If Yes, explain if you wish.
Taxi Freight LLC101 Colony Park Drive Suite 300 Cumming GA 30040
Please complete and fax application to 1-866-591-8483Phone: 770-871-5015
EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employersduring the preceding 10 years. List complete mailing address, street number, city, state and zip code. Backgroundcheck will be performed for the previous 3 years.
(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
EMPLOYER DATENAME
FROM MO YR
TO MO YR
ADDRESS POSITION HELD
CITY STATE ZIP SALARY/WAGE
CONTACT PERSON PHONE NUMBER REASON FOR LEAVING
Subject to FMCSR's while employed? YES NO Was this job designated as safety-sensitive in any DOT regulated mode subject to alcohol & controlled substances testing?
YES NO
EMPLOYER DATENAME
FROM MO YR
TO MO YR
ADDRESS POSITION HELD
CITY STATE ZIP SALARY/WAGE
CONTACT PERSON PHONE NUMBER REASON FOR LEAVING
Subject to FMCSR's while employed? YES NO Was this job designated as safety-sensitive in any DOT regulated mode subject to alcohol & controlled substances testing?
YES NO
EMPLOYER DATENAME
FROM MO YR
TO MO YR
ADDRESS POSITION HELD
CITY STATE ZIP SALARY/WAGE
CONTACT PERSON PHONE NUMBER REASON FOR LEAVING
Subject to FMCSR's while employed? YES NO Was this job designated as safety-sensitive in any DOT regulated mode subject to alcohol & controlled substances testing?
YES NO
EMPLOYER DATENAME
FROM MO YR
TO MO YR
ADDRESS POSITION HELD
CITY STATE ZIP SALARY/WAGE
CONTACT PERSON PHONE NUMBER REASON FOR LEAVING
Subject to FMCSR's while employed? YES NO Was this job designated as safety-sensitive in any DOT regulated mode subject to alcohol & controlled substances testing?
YES NO
ACCIDENT HISTORY
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
DATES NATURE OF ACCIDENT (head-On, Rear-End, etc.) INJURIES
LAST ACCIDENT NEXT PREVIOUS NEXT PREVIOUS
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
LOCATION DATE CHARGE
ATTACH SHEET IF MORE SPACE IS NEEDED
EDUCATION CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4
LAST SCHOOL ATTENDED: NAME:
EXPERIENCE AND QUALIFICATIONS STATE LICENSE NO. TYPE EXPIRATION DATE
DRIVER LICENSES
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 been suspended or revoked? Yes No
IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS
DRIVING EXPERIENCE IF NONE, WRITE NONECLASS OF EQUIPMENT TYPE OF EQUIPMENT DATES APPROX. # MILES (VAN, TANK, FLAT, ETC.) FROM TOTAL
STRAIGHT TRUCK
TRACTOR/ SEMI-TRAILER
TRACTOR/ TWO TRAILERS
MOTORCOACH/SCHOOL BUS
OTHER
LIST ALL STATES WHERE YOU HELD A CDL LICENSE OR CDL PERMIT IN THE PAST THREE YEARS:
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
EXPERIENCE AND QUALIFICATIONS - OTHER SHOW ANY TRUCKING, TRANSPORTATION OR OTHER DRIVING EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN ALREADY SHOWN)
TO BE READ AND SIGNED BY APPLICANT 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. I authorize you to make such investigations and inquiries of my personal,employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. This includes contacting previous employers for the purpose of investigating my safety performancehistory as required in 391.23. I realize I have the following rights: The right to review information provided by myprevious employers. The right to have errors in the information corrected by the previous emplyers. The right to have a rebuttal statement attached to the alleged eroneous information if the previous employer and I cannotagree on the accuracy of the information. (Generally, inquiries regarding medical history will be made only if andafter a conditional offer of employment has been extended.) I hereby release employers, schools, health careproviders and other persons from all liability in responding to inquiries and releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
Date Applicant's Signature
PROCESS RECORD APPLICANT HIRED REJECTED DATE EMPLOYED POINT EMPLOYED DEPARTMENT CLASSIFICATION (IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)
THIS SECTION TO BE FILLED IN BY RESPONSIBLE OFFICER OR COMPANY REPRESENTATIVE
SUPERIOR GOOD FAIR BELOW AVERAGE WRITTEN RECORD ON FILE1. APPLICATION 2. INTERVIEW 3. PAST EMPLOYMENT 4. WRITTEN EXAM 5. ROAD TEST 6. CRIMINAL AND 7. TRAFFIC CONVICTIONS
SIGNATURE OF INTERVIEWING OFFICER
TRANSFERS FROM: TO: FROM: TO: DATE: DATE: REASON FOR TRANSFER: REASON FOR TRANSFER:
FROM: TO: FROM: TO: DATE: DATE: REASON FOR TRANSFER: REASON FOR TRANSFER:
TERMINATION DATE TERMINATED: DEPARTMENT RELEASED FROM:
DISMISSED: VOLUNTARILY QUIT OTHER:
TERMINATION REPORT PLACED IN FILE SUPERVISOR:
PROGRAM PARTICIPANT AGREEMENT
ALL NEW HIRES OR TRANSFERS TO A CDL POSITION MUST HAVE A PRE-
EMPLOYMENT DRUG SCREEN. PLEASE USE THE CHAIN OF CUSTODY FORM PROVIDED BY THE TRANSPORTATION ADVISOR TO PERFORM THIS
TEST. I am aware of the company’s drug and alcohol policy. I agree to read and abide by the company’s policy of having a drug and alcohol free workplace. My signature acknowledges receipt of a formal information packet outlining both company and driver responsibilities under 49 CFR part 382 and part 40. Company Name: ___________________ __________________ Print Name Social Security #
__________________________________________________ Driver’s Signature Date Date of pre-employment drug screen: ____________________________
THIS DRIVER WILL NOT BE ACTIVATED IN RANDOM POOL WITHOUT A PRE-EMPLOYMENT DRUG SCREEN RESULT ALONG WITH THIS FORM.
UPON SIGNING PLEASE FAX BACK TO THE TRANSPORTATION ADVISOR
Phone: 800-608-8890 Fax: 413-284-0022 [email protected]
DF - 6
DRIVER STATEMENT OF ON-DUTY HOURS (For Newly Hired Drivers)
INSTRUCTION: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form. Driver Name (Print) _________________________________________________________________________________ Social Security Number _____________________________________________________________________________ Driver’s License: State _____ Number _________________ Class _____ Endorsement(s) ______ Restriction(s) _______ Type of License __________________________________ Issuing State ______________________________________
DAY 1 (yesterday)
2 3 4 5 6 7
DATE
HOURS WORKED
TOTAL HOURS
I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at A.M. ___________________ P.M. On _________________________________ Time Day Month Year _____________________________________________ ______________ Driver’s Signature Date
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK
INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, also performing any compensated work for any nonmotor carrier entity. (check one) Are you currently working for another employer? □ Yes □ No At this time do you intend to work for another employer while still employed by □ Yes □ No this company? I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity. ____________________________________________ ________________ Driver’s Signature Date
Witness: ____________________________________________ ________________ Company Representative Date
Phone:
Fax:
Job Title:
Termination Date: _______________ Resigned: Yes No Discharged: Yes No
If Discharged, why?________________________________________________________________________________
Equipment:
Accidents:
Violated other D.O.T. drug/alcohol regulations?
_________________________________________________________
Applicant's Printed Name
Applicant's Signature Date
Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information, must
submit a written request to the Safety Compliance Manager of Taxi Freight LLC, which may be done at any time, including when applying, or as late as thirty (30) days after being employed or
being notified of denial of employment. Taxi Freight LLC will provide this information to the applicant within five (5) business days after receiving the written request. If, however, Taxi Freight LLC
has not yet received the requested information from the previous employer(s), then it will provide the information to the applicant within five (5) business days after it receives the requested safety
performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of Taxi Freight LLC making them available, Taxi Freight LLC will
consider the driver to have waived the request to review the records.
Yes _____ No _____
Yes _____ No _____
Person Providing Information
Applicant's Due Process Rights: 1) The right to review information provided by previous employers; 2) 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 Taxi Freight LLC; and 3) The right to have a rebuttal statement attached to the alleged errneous information, if the previous employer and
the driver cannot agree on the accuracy of the information.
It is expressly acknowledged, understood and agreed that the information provided by the applicant regarding the applicant's employment during the previous three (3) years in accordance with Section
391.21(b)(10) of the Federal Motor Carrier Safety Regulations ("FMCSR") may be used, and the applicant's prior employers may be contacted, for the purpose of investigating the applicant's safety
performance history information as required by paragraphs (d) and (e) of Section 391.23 of the FMCSR. The applicant has certain due process rights under the FMCSR regarding the information
received as a result of these investigations, as described below.
Name of Applicant: _______________________________________
# Preventable: ______________
Commodities Hauled: _____________________________________________________________________________
1.) I hereby authorize the above-mentioned employer/school to release all information as to my character, work habits, performance, experience, fitness, together with reasons for termination
concerning my employment to Taxi Freight LLC (or their authorized agents) which may request such information in connection with my application for employment with Taxi Freight LLC 2.) In
conformity with 49 CFR part 40, I hereby authorize the above-mentioned employer/school and their agents to furnish Taxi Freight LLC the above-requested information concerning D.O.T. drug and
alcohol tests including pre-employment tests during the previous 3 years; the dates when I tested positive; the dates when I tested .04 or greater; the dates when I refused (including a verified
adulterated or substituted result) to be tested for drugs and alcohol; and any other violations of 49 CFR part 40 and any information the above-mentioned employer/school and/or their authorized
agents have received regarding violations of 49 CFR part 40 from my previous employers covered by D.O.T.
3.) I hereby release the above-mentioned employer/school and their authorized agents from any and all liability of any type as a result of providing the above-requested information to Taxi Freight LLC
Refrigerated _____ Flatbeds _____ Vans _____ Tanker _____ Other _____
Have you received information from a previous employer that this individual has violated D.O.T.
drug/alcohol regulations?
Ever refused a required test for drugs or alcohol in the last 3 years?
Description: ______________________________________________
# Non-Preventable: __________ Description: ______________________________________________
Drug/Alcohol information below requested in accordance with DOT 49 CFR Part 40. (Tests done in last 36 months.)
________________________________________________________________________________________________
By signing below, I certify that I have read and fully understand Parts 1, 2, and 3 of this release and that I executed this release voluntarily, with the knowledge that any and all information
released could affect my being employed with Taxi Freight LLC
Yes _____ No _____
Yes _____ No _____
Had a breath alcohol test result with a concentration of .04 or greater in the last 3 years? Yes _____ No _____
Sent to: ____________________________________________
If Yes, please give type of test, date of test, and SAP information (if applicable): ______________________________
______________________________________Title
PAST EMPLOYMENT VERIFICATION
Tested positive for controlled substance in last 3 years?
Poor _____ Fair _____ Good _____ Excellent _____
Social Security #: ______________________
Taxi Freight LLC101 Colony Park Drive, Cumming GA 30040
Fax Number: __________________________Previous Employer
Requested by: 1-770-871-50151-866-591-8483
Witness
Areas of Operation: _______________________________________________________________________________
Hire Date: _________________
Type of Tractor/Truck: ______________________________________ Trailer Length: _______________
Eligible for Rehire? Yes _____ No _____ Upon Review _____ If No, please explain: ______________________
Accident information below requested in accordance with FMCSR Part 391.23. (Accidents within last 36 months.)
Overall Performance: