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DOT Employment Application – Long Form

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  • Any Question that You Find An ( * ) Asterisk Next To In This Application Must Be Answered In Order To Complete Your Online Application.

  • In compliance with Federal and State equal opportunity Laws, qualified applicants are considered for all positions without regard to race, religion, sex, nation origin race, marital status, or non-job related disability.

  • TO BE READ AND SIGNED BY APPLICANT

  • By Typing your name into this application, you are affriming you are the bonafide applicant.

  • PERSONAL INFORMATION

  • PREVIOUS ADDRESSES FOR PAST (3) YEARS

  • FIRST ADDRESS:

    If You Answered "Yes" To The Question Above Please List Them Below:

  • SECOND ADDRESS:

  • THIRD ADDRESS:

  • WORK EXPERIENCE

  • Federal Motor Carrier Regulations: In accordance with 391.21 & .23 of the Federal Motor Carrier Regulations (FMSCR), an application must list all previous work experience for the past (3) years prior to the date shown on page one, as well as all commercial driving experience for seven (7) years prior to those three years, for a total of 10 years. If you are an owner operator, list carriers leased to.

  • CURRENT OR PREVIOUS EMPLOYER

    PLEASE LIST STARTING WITH THE MOST RECENT EMPLOYER,  USE THE "Work Experience Addendum" IF NEEDED.

    If You Answered "YES" To The Question Above Please List Them Below.

  • Please Give A Detailed Answer.

  • SECOND LAST EMPLOYER COMPANY

  • Third Last Employer Name:

  • The Federal Motor Carrier Safety Regulations apply to everyone operating a motor vehicle on a highway in the interstate commerce to transport passengers or property when the vehicle:

    1. Weighs or has a GVWR or 10,001 pounds or more.

    2. Is designed or used to transport 9 or more passengers.

    3. Is of any size and is used to transport hazardous materials in a quantity requiring placarding. *Any gaps in employment and/or unemployment must be explained *

  • COMMERCIAL DRIVER'S LICENSE INFORMATION

  • (A, B or C)

  • List Any Additional Licence(S) Held In The Past 3 Years.

    If You Answered Yes To The Above Question Please list them below:

  • COLLISIONS

  • Please List All Motor Vehicle Collisions In Which You Were Involved (Both Commercial, AND Private Vehicle) During The Past 3 Years Prior To The Application Date.

    If You Answered Yes To The Above Question Please list them below:

  • First Collision If Any:

  • Second Collision If Any:

  • Third Collision If Any:

  • TRAFFIC CONVICTIONS AND/OR FORFEITURES

  • Please List All Traffic Convictions and/or Forfeitures In (Both Commercial, AND Private Vehicle) During The Past 3 Years (Other Than Parking) Prior To The Application Date.

    If You Answered Yes To The Above Question Please list them below:

  • First Traffic Conviction And/Or Forfeiture If Any:

  • Second Traffic Conviction And/Or Forfeiture If Any:

  • Third Traffic Conviction And/Or Forfeiture If Any:

  • DRIVING EXPERIENCE

  •  

    Equipment Class - Type Of Equipment - Dates - Approx. Miles Driven

  • Strait Truck

  • Type Of Equipment (Van, Tank, Flat, Ect.)

  • Tractor & Semi Trailor

  • Type Of Equipment (Van, Tank, Flat, Ect.)

  • Other:

  • Type Of Equipment (Van, Tank, Flat, Ect.)

  • List Commodities Hauled:

  • Education

    If You Answered Yes Please Explain Below:

  • General

  • In Case Of Emergency, Contact:

  • This Must Be Read And Signed By Applicant

    I authorize the carrier to make such inquiries and investigations of my personal, employment, driving, finacial,or medical history andand other related mattersas maybe nessary in arriving at an employment decision. (Gennerally, inquiries reguarding medical history will be made only if and after a conditional offer of employment has been extended.) I here by release employers, schools, health care providers and other persons from all liability in responding to inquiries and relasing imformation with my application.

    In the event of enployment, I understand that false or misleading information givin in my application or interview (s) my result in discharge. I agree to abide by the rules and regulations of the carrier as well as the Fereral Motor Carrier Safty Regulations. I also agree and understand that if I am selected to drive for the carrier I will be on probationary period during which time I may be discharged without recoarse.

  • By Typing your name into this application, you are affriming you are the bonafide applicant.

  • Work Experience Addendum

    If You Answered "Yes" To The Above Question Please list them below:

    If "No" Go To Next Page:

  • Forth or Last Employer Company Name:

  • Fifth or Last Employer Company Name:

  • Sixth or Last Employer Company Name:

  • The Federal Motor Carrier Safety Regulations apply to everyone operating a motor vehicle on a highway in the interstate commerce to transport passengers or property when the vehicle:

    1. Weighs or has a GVWR or 10,001 pounds or more.

    2. Is designed or used to transport 9 or more passengers.

    3. Is of any size and is used to transport hazardous materials in a quantity requiring placarding. *Any gaps in employment and/or unemployment must be explained *

  • MOTOR VEHICLE DRIVER'S CERTIFICATION OF VIOLATIONS

    If You Have Had "No" Violations Select "None"

    If You Selected "Yes" To The Above Question, Please list them below:

  • Violation #1

  • e.g. speeding 69/55 ect.

  • Violation #2

  • e.g. speeding 69/55 ect.

  • Violation #3

  • e.g. speeding 69/55 ect.

  • Violation #4

  • e.g. speeding 69/55 ect.

  • Driver/License Information

    If no violations are listed above:

  • By Typing your name into this application, you are affriming you are the bonafide applicant.

  • HURRICANE SPECIALIZED
    975 JOHNSON AVE.
    FRANKLIN, IN 46131

  • COMPANY USE ONLY - ANNUAL REVIEW OF DRIVING RECORD

  • At least once every 12 months a review of a driver's record must be preformed to determine whether the driver meets the minimun requirments for safe driving or is disqualified to drive a motor vehicle pursuant to section 391.15. The driver shoild complete the top form, and thr carrier should complete the bottom.

    In accordance with Section 391.25 FMCSR, all information pertant to the above driver's safty of operation, including all collisions, and the list of violations furnished by him/her in accordance with 391.27 FMCSR for the past 12 months has been reviewed.

  • Supervisor's Signature

  • CERTIFICATE OF COMPLIANCE WITH DRIVERS LICENCE REQUIREMENTS

  • The Motor Carrier Safety Regulations part 383, applies to every person who operates a commercial motor vehicle in interstate commerce, who operates a vehicle with a gross weight rating 26,001 pounds or more, can transport 16 or more passengers including the driver, or transports hazardous materials that require placarding.

    If the above applies you must comply with the following:

    1. A driver may not possess more than one license. A motor carrier may not use a driver with more than one license. The driver's license must be from the driver's state of domicile.

    2. A driver who violates state and/or local traffic laws (other than parking ticket) must notify the motor carrier and the state that issued the license, within thirty days after the violation occurred.

    3. A driver who receives either a revocation or suspension of their license must notify the motor carrier the next business day after receiving the notice.

    4. A driver must provide previous work history when applying to operate a commercial motor vehicle.

    I hereby agree that I have read and understand the above requirements issued in the Federal Motor Carrier Safety Regulations. The following license is the only one I possess.

  • By Typing your name into this application, you are affriming you are the bonafide applicant.

  • SAFTEY PERFORMANCE HISTORY RECORDS REQUEST DRUG/ALCOHOL TESTING AND ACCIDENT HISTORY

  • Part #1: To Be Completed By Prospective Employee:

  • Here by authorize my previous employer to release and foward the information requested below concerning my aolchol and controlled substances testing and accident history records within the previous (3) years from the date of my employment application. The information should be sent to my prospective employer to the address by confidential fax or confidential email shown below:

  • By Typing your name into this application, you are affriming you are the bonafide applicant, and our authorizing release of your safety performace history records, drug/aolchol testing, and accident history.

  • The information should be sent to my prospective employer:

  • Authorization: to be sent to the address, confidential fax, or confidential E-mail shown below:

  • By Typing your name into this application, you are affriming you are the bonafide applicant.

  • After You The Applicant Have Filled Out This Short Section Move On To The "Next Page" Of The ApplicationPlease".

  • Part #2 To Be Completed By Prospective Employer.

  • Please take a moment and complete the information requested in Part 3. We would appreciate your prompt responce. As you are aware, after October 29, 2004, failures to respond within 30 days to investigate requests for safety performance history will result in a complaint notification being filled with the Federal Motor Carrier Safty Administraition using the complaint process specified at 386.12 of the Federal Motor Carrier Safety Regulations. 

  • Part 3: To Be Completed By Previous Employer

    If "YES", Please State The Actual Dates Of Employment Below:

  • Part 3 Continued:

    If You Selected "YES" To The Question Above, Please List Them Below.

  • Accident #1

  • Accident #2

  • Accident #3

  • Drug and Alcohol History

    If You Selected "YES" Please Answer Questions Below.

    If You Selected "NO" Proceed to The Bottom Of This Section and Sign.

  • Applicant Was Subject To DOT Testing Requirements From:

  • In answering these questions, include any required DOT drug or alcohol testing information obtained from past or previous employers in the previous 3 years prior to this application date shown above. Include supplemental sheets, if necessary.

  • By Typing your name into this application, you are affriming you are the bonafide applicant.

  • Part 4 to be completed by prospective employer

  • Driver Applicant Pre-Employment Alcohol And Controlled Substance Statement

  • Section 40.25(J) of the Federal Motor Carrier Safety Regulations, requires each motor carrier to inquire of prospective drivers are required to respond to the information in the question below.

    If the answer to the above question is "YES", please list the motor carrier(s) below:

  • In addition, if the answer to the above question was YES, please list the name and contact information for the Substance Abuse Professional (SAP) who completed your evaluation.

  • By Typing your name into this application, you are affriming you are the bonafide applicant.

  • Driver's Rights Under

    FMCSR 391.23

  • As a driver you are provided with certain rights the Federal Motor Carrier Safety Regulations in Part 391.23. These rights are:

    391.23(i)(1)

    (i) The right to review information provided by previous employers;

    (ii) The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer.

    (iii) The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

    391.23(i)(2) 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 prospective employer. Which may be done at any time, including when applying, or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five(5) business days of receiving the written request. If the prospective employer has not received the requested information from the previous employer(s), then the five(5) business days deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within the thirty(30) days of the prospective employer making them available, the prospective motor carrier may consider to have waived his/her request to review the records.

    391.23(i)(1) Drivers wishing to request correction of erroneous information in records received pursuant to paragraph (i) of this section must send the request for the correction to the previous employer that provided the records to the prospective employer.

    391.23(i)(2) After October 29, 2004 the previous employer must either correct and forward the information to the prospective motor carrier employer, or notify the driver within 15 days of receiving a driver’s request to correct the data that it does not agree to correct the data. If the previous employer agrees to correct and corrects and forwards the data as requested, that employer must also retain the corrected information as part of the driver’s safety performance history record and provide it to subsequent prospective employers when requested for this information and received. If the previous employer corrects the data and forwards it to the prospective motor carrier employer, there is no need to notify the driver.

    391.23(i)(3) Driver’s wishing to rebut information in records received pursuant to paragraph (i) of this section must send the rebuttal to the previous employer with instructions to include the rebuttal in that driver’s safety performance record.

    391.23(i)(4) After October 29, 2004, within five business days of receiving a rebuttal form a driver , the previous employer must:

    (i) Forward a copy of the rebuttal to the prospective motor carrier employer;

    (ii) Append the rebuttal to the driver’s information in the carrier’s appropriate file, to be included as part of the response for any subsequent investigating prospective employers for the duration of the three(3) year data retention requirement.

    391.23(i)(5) The driver may submit a rebuttal initially without a request for correction, or subsequence to a request for correction.

    391.23(i)(6) The driver may report failures of previous employers to correct information or include the driver’s rebuttal as part of the safety performance information, to the FMCSA following procedures specified at section 386.12.

    391.23(k)(1) The prospective motor carrier employer must use the information described in paragraphs (d) and (e) of this section only as part of deciding whether to hire the driver.

    391.23(k)(2) The prospective motor carrier employer, its agents and insurers must take all precautions reasonably necessary to protect the records from the disclosure to any person not directly involved in deciding whether to hire the driver. The prospective motor carrier employer may not provide any alcohol or controlled substance information to the prospective motor carrier employer’s insurer.

    391.23(1)(1) No action or proceeding for defamation, invasion of privacy, or interference with a contact that is based on the furnishing or use of information in accordance with this section may be brought against:

    (i) A motor carrier investigating the information, paragraphs (d) and (e) of this section, of an individual under consideration for employment as a commercial motor carrier driver.

    (ii) A person who has provided such information; or

    (iii) The agents or insures of a person described in paragraph (1)(1)(i) or (ii) of this section, except insurers are not granted a limitation on liability for any alcohol and controlled substance information.

    391.23(1)(2) The protections in paragraph (1)(1) of this section do not apply to persons who knowingly furnish false information, or who are not compliant with procedures specified for theses investigations.

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