Driver's Application for Employment
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.
TO BE READ AND SIGNED BY APPLICANT
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. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers 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. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand I have the right to:
• Review information provided by previous employers;
• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
▪ Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
Termination of Employment
This form is made available with the understanding that J. J. Keller & Associates, Inc. is not engaged in rendering legal, accounting, or other professional services. J. J. Keller & Associates, Inc. assumes no responsibility for the use of this form or any decision made by an employer which may violate local, state or federal law.
Application to Complete
(answer all questions)
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code.
Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle.
(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
1
2
3
4
5
Includes vehicles have a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity.
ACCIDENT RECORD for past 3 years or more (Attach sheet if more space is needed if none, write None.
Nature of Accident
(Head-on, Rear-end, Upset, ect.)
TRAFFIC CONVICTIONS and forfeitures for the past 3 years (other than parking violations) If none, write None.
(Attach sheet if more space is needed)
EXPERIENCE AND QUALIFICATIONS - DRIVER
List all Driver Licenses or permits held in the past 3 years
DRIVING EXPERIENCE
Check that Apply
Which Type of Equipment
(Van, Tank, Flat, Dump, Refer)
Dates
From (M/Y) - To (M/Y)
Approx. No. of Miles (Total)
EXPERIENCE AND QUALIFICATIONS - OTHER
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.
Candidate: Complete Section 1 ONLY and return with application
SAFETY PERFORMANCE HISTORY RECORDS REQUEST
TO BE COMPLETED BY PROSPECTIVE EMPLOYEE
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from:
This information is being requested in compliance with §40.25(g) and §391.23(h).
Side Section 1: Prospective Employee
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Complete the information required in this section
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