Employment Application Step 1 of 4 25% Driver’s ApplicationWarehouse ApplicationPosition applied for Driver Warehouse Employee DOT REGULATED DRIVER APPLICANT’S RIGHTS As an applicant for a driver position regulated by the United States Department of Transportation, Federal Motor Carrier Safety Administration, you are advised that all information supplied by you in connection with your application will be investigated as required under 49 CFR 391.23 and may be used in the determination of the suitability of your application for the position that is being offered. As a driver applicant you have the following rights: (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. (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 being 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 yet received the requested information from the previous employer(s), then the five-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 Thirty {30} days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records. (j)(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. (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 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 requests for this information are 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. (3) Drivers 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 history. (4) After October 29, 2004, within five business days of receiving a rebuttal from 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-year data retention requirement. (5) The driver may submit a rebuttal initially without a request for correction, or subsequent to a request for correction.(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 ยง386.12. (Approved by the Office of Management and Budget under control number 2126-0004) THIS CERTIFIES THAT I HAVE READ AND RECEIVED A COPY OF THE ‘APPLICANTS RIGHTS.’Signature General InformationName First Last DOB MM slash DD slash YYYY SSN (last 4 digits)Email PhoneCurrent Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are you eligible to work in the US? Yes No In case of emergency notify: First Last Emergency Contact PhoneEmergency Contact Address Street Address Address Line 2 City State ZIP Have you worked for this company before? Yes No Date from MM slash DD slash YYYY Date to MM slash DD slash YYYY PositionReason for leavingAre you now employed? Yes No How long since leaving your last employment?Who referred you?Pay rate expected (per hour) Physical HistoryAre you able to preform the duties described belowAbility to push, pull, crank, turn, lift and carry 50 pounds. Ability to use steps to climb into and out of truck cab. Continuously bend, stoop, kneel, squat. Ability to throw chain and strap over cargo on trailer and secure using a winch bar. Ability to place dunnage on trailer for loading and remove dunnage from trailer once unloaded. Yes No List any limitations that prevent you from performing the duties listed. Specify any medical waivers.Employment HistoryEnter the past 7 years of employment history.Employee Row ID Employer From To Actions Edit Delete There are no Employees. Add Employer Maximum number of employees reached. Employee Row ID Employer From To Actions Edit Delete There are no Employees. Add Employer Maximum number of employees reached. Accident RecordEnter all accident records for the past 3 years.Accident History Row ID Nature of Accident Date Injury Fatalities Actions Edit Delete There are no Accidents. Add Accident Maximum number of accidents reached. Traffic Convictions & ForfeituresEnter all traffic convictions & forfeitures for the past 3 years.Traffic Violations Row ID Location Date Charge Penalty Actions Edit Delete There are no Traffic Violations. Add Traffic Violation Maximum number of traffic violations reached. Experience & QualificationsValid license currently heldStateLicense NumberTypeExpiration Date MM slash DD slash YYYY Driving ExperienceType of equipment & approximate miles/hours driven.Class Straight Truck Tractor/Trailer Doubles Type Van Tank Flat Other MilesFromToHave you even been denied a license, permit or priviledge to operate a motor vehicle? Yes No Has any lincese, permit or priviledge ever been suspended or revoked? Yes No Explain detailsIn the past 5 years, have you tested positive, or refused to test, on a pre-employment drug or alcohol test administered by an employer where you applied for a safety sensitive position and were not hired? Yes No List states licensed in for past 5 yearsConsent and SignatureSignature