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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. 

FOR COMPANY USE

Process Record

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)

Current Address

Previous 3 Addresses

When:

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.

Employment History

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.)

Employer

Date

1

Were you subject to the FMCSRst while employed?
Was your job designated as a safety-sensitive function in any dot- regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Employer

Date

2

Were you subject to the FMCSRst while employed?
Was your job designated as a safety-sensitive function in any dot- regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Employer

Date

3

Were you subject to the FMCSRst while employed?
Was your job designated as a safety-sensitive function in any dot- regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Employer

Date

4

Were you subject to the FMCSRst while employed?
Was your job designated as a safety-sensitive function in any dot- regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Employer