APPLICATION

Please fill out the form below and click the submit button.
MUST BE A U.S. RESIDENT
All Fields with an asterick (*) are required.
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without reqard 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 offoer 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 49CFR 391.23(d) and (e). I understand that I have the right to:

  • Review informatin 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 aggree on the accuracy of the information.

Signature/Date
CONTACT INFORMATION:
* Last Name
 * First Name
* Middle Name
* Social Security #
* Night Phone
* Day Phone
* Date of Birth
E-mail
* Best Time to Call
 
List your addresses of residency for the past 3 years
Current Address
* Street Address
 * City
* Zip/Postal Code
 * State
How long?
Previous Address 1
* Street Address
 * City
* Zip/Postal Code
 * State
How long?
Previous Address 2
* Street Address
 * City
* Zip/Postal Code
 * State
How long?
Previous Address 3
* Street Address
 * City
* Zip/Postal Code
 * State
How long?

CURRENT DRIVER LICENSE INFORMATION:
• Date of Birth ( mm/dd/yyyy) (Required for Commercial Drivers)
Who referred you?
Have you ever been convicted of a felony?
License Number
 Class:
 
Class A Class B Class C
State                                  Expiration Date
 
   
Endorsements:
 

Hazmat		 Double/Triple
Tanker

DRIVING INFORMATION:
I prefer to run: (check all that apply)


Southeast

Southwest

Midwest

Northeast

Northwest

Local
Experience:

HHG
Tanker
Flatbed
Van
Reefer
Specialized
Auto Carrier
Hazmat
Double/Triple
* Years of Tractor Trailer Driving Experience
Driver School Graduate:

Yes No
Traffic Convictions:
(past three years, other than parking violations) 
Number of Accidents:
(past three years)
 
* I am now a:

Owner Operator
Company Driver
Student
 I Would Like to Run

Single
Team
Husband/Wife
I Prefer to Pull:

HHG
Tanker
Flatbed
Van
Reefer
Specialized
Auto Carrier
Hazmat
Double/Triple

TYPE OF EQUIPMENT DATES APPROX. NO. OF MILES (TOTAL)
VAN TANK FLAT DUMP REFER
VAN TANK FLAT DUMP REFER
VAN TANK FLAT DUMP REFER

Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes
 No
Has any license, permit or privilege ever been suspended or revoked? Yes
 No
Do you have restriction to drive in Canada? Yes
 No

Show any trucking, transportation or other experience that may help your work for this company
EMPLOYMENT INFORMATION:
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 intrasttate 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.)
CURRENT EMPLOYER:
Street / City / State / Zip:
DATE
From mm/yyyy
 To mm/yyyy
Position held
Salary/Wage
Reason for leaving
Phone Number:
Were you subject to the FMCSRs** while employed? Yes
 No
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
 No
PAST EMPLOYER 1:
Street / City / State / Zip:
DATE
From mm/yyyy
 To mm/yyyy
Position held
Salary/Wage
Reason for leaving
Phone Number:
Were you subject to the FMCSRs** while employed? Yes
 No
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
 No
PAST EMPLOYER 2:
Street / City / State / Zip:
DATE
From mm/yyyy
 To mm/yyyy
Position held
Salary/Wage
Reason for leaving
Phone Number:
Were you subject to the FMCSRs** while employed? Yes
 No
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
 No
PAST EMPLOYER 3:
Street / City / State / Zip:
DATE
From mm/yyyy
 To mm/yyyy
Position held
Salary/Wage
Reason for leaving
Phone Number:
Were you subject to the FMCSRs** while employed? Yes
 No
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
 No
PAST EMPLOYER 4:
Street / City / State / Zip:
DATE
From mm/yyyy
 To mm/yyyy
Position held
Salary/Wage
Reason for leaving
Phone Number:
Were you subject to the FMCSRs** while employed? Yes
 No
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
 No
* Includes vehicles having a GVWR or 26,001 lbs or more, vehicles designed to transport 15 or more passengers, or any size vehicle to transport materials in 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 requiring placarding.

ACCIDENT RECORD (if any):

For the past 3 years or more
DATES
NATURE OF ACCIDENT
(Head-on, Rear-end, Upset, etc.)
FATALITIES
INJURIES
HAZARDOUS MATERIAL
Last Accident mm/dd/yyyy
Next Previous mm/dd/yyyy
Next Previous mm/dd/yyyy

TRAFFIC CONVICTIONS (if any):

and forteitures for the past 3 years (other than parking violations)
LOCATION
DATE
CHARGE
PENALTY
Attach your CDL (optional)
Additional Comments:
By submitting this application I certify that I personally completed this application and that all of the information is true and correct. I hereby request and authorize Carrier Companies and their agents or contractors that receive this application to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I have completed this application of my own free will and hold harmless of all liability all companies, agents and associated parties for the use of this application. As part of our consideration of your application, the DOT requires companies to investigate your employment background. As part of this investigation, they may obtain consumer reports about you from DAC Services. DAC is a consumer reporting agency. Any decision they make not to hire you based on information contained in your consumer report will be their decision alone. DAC does not make any decisions concerning your employment with these companies and will not know the specific reasons why they may decide not to hire you. In the event you are not hired based on information contained in your consumer report, the companies themselves will tell you. We will also advise you of your right to obtain a free copy of the consumer report from DAC and your right to dispute the accuracy or completeness of your report. Your consent for these companies to obtain the report from DAC is required. Although you have a right to withhold your consent, companies will not consider your application if you withhold your consent.

I have read the above release and I give permission to obtain consumer reports about me from DAC.

Yes   |   No
Copyright 2008 LCL Bulk Transport, Inc.