Driver Application Form

COMERCIAL DRIVER APPLICATION

Rom Trans Inc

APPLICANT INFORMATION

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Date

Position applying for

Phone

Emergency Phone

Age

Date of birth

SS#

The Age Discrimination of Employment Act of 1976 prohibits discrimination on the basis of aage with respect to indivuals who are at least 40 but less then 70 years of age.

Physical Exam Expiration Date

Current and previous three years adresses

From

Current and previous three years adresses

From

Current and previous three years adresses

From

HAVE YOU WORKED FOR THIS COMPANY BEFORE

Yes

If Yes, give dates

From

Reason for leaving?

EDUCATION HISTORY:

Please choose the highest grade completed

Grade school

College

Post Graduate

EMPLOYMENT HISTORY:

Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years.

From

Present or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

From

Present or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

From

Present or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

From

Present or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

From

Present or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

From

Present or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

From

Present or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

DRIVING EXPERIENCE

Class of Equipment

Tractor & Semitrailer

From

Approximate No. of Miles

Tractor & two trailers

From

Approximate No. of Miles

Straight Truck

From

Approximate No. of Miles

Other

From

Approximate No. of Miles

List states operated in, for the last five (5) years:

List special courses/training completed (PTD/DDC, HAZMAT, ETC)

List any Safe Driving Awards you hold and from whom:

Accident Record for past three (3) years:

Date of Accident

Nature of Accidents (Head on, rear end, etc)

Location of Accident

At fault

# of People Injured

Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):

Date

Location

Charge

Penalty

Driver’s License (list each driver’s license held in the past three(3) years:

State

License

Type

Endorsements

Expiration Date

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

Yes

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

Yes

Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?

Yes

Have you ever been convicted of a felony?

Yes

If the answers to any questions listed above are “yes”, give details

Job References

List three (3) persons for references, other than family members, who have knowledge of your safety habits.

Name

Address

Phone

To Be Read and Signed by Applicant:

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to obtain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

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 confirm that I have read

I confirm

Applicant Signature

Date

Rom Trans Inc

PREVIOUS EMPLOYMENT VERIFICATION

PLEASE RETURN AS SOON AS POSSIBLE!!!

To (Previous Employer)

Date

Applicant Name

SS#

The person listed above has applied to this company. Your firm is listed by the applicant as a previous employer. Please complete the following items and return to us as soon as possible.

Dates of Employment

From

Position

Three-Year Accident History

Date

City / State

# Injuries

# Fatalities

Hazmat

Preventable

Why did this employee leave your company?

Resigned

Discharged

Laid Off

Would you rehire this person?

Yes

Please explain

Department of Transportation regulations (40 CFR, Part 40.25 (h) requires that you provide the following information:

As an employee of your company, has the individual listed below ever:

Had a verified positi ve drug test result?

Yes

Had an alcohol test result with a breath alcohol concentration of .04 or greater?

Yes

Had an alcohol test result with a breath alcohol concentration of .04 or greater?

Yes

Refused to submit to an alcohol or drug test?

Yes

Had any other violations of DOT agency drug and alcohol testing regulations?

Yes

Had any other violations of DOT agency drug and alcohol testing regulations?

Yes

If any of the above questions were answered yes, please provide the following:

Substance Abuse Professional

Telephone

Date Referred

Adress

City

State

Zip

Signature of person supplying information

___________________________

Title / Date

___________________________

APPLICANT RELEASE AND CONSENT

I, do hereby authorize my previous employers to release and forward all information regarding my alcohol and controlled substance testing and all other records of employment to the above named carrier in connection with my application for employment. I release my former employers from any and all liability of any type as a result of providing the above information.

Applicant Name (Signature)

Date

Witness Name (Signature)

Date

MVR RELEASE CONSENT FORM

In conjunction with my potential employment at Rom Trans Inc (“the company”), I

(applicant) consent to the release of my Motor Vehicle Records (MVR) to the company. I understand the company will use these records to evaluate my suitability to fulfill driving duties that may be related to the position for which I am applying. I also consent to the review, evaluation, and other use of any MVR I may have provided to the company.

This consent is given in satisfaction of Public Law 18 USC 2721 et. Seq., “Federal Drivers Privacy Protection Act”, and is intended to constitute “written consent” as required by this Act-

Signed (applicant)

Date

Drivers’ License Number

State

Rom Trans Inc

Rom Trans Inc

Rom Trans Inc

Pages

Working Hours