Full Legal Name
Street Address
City
State
Zip
Name
Phone
Street
Dates
date
Email
tel
Date of Birth
Drivers only to complete Date of Birth
Social Security No.
Have you ever worked for this company under another name?
Are you applying as a company driver or an owner operator?
Are you currently employed?
When are you available to start work for this Company?
How long are willing to be away from home?
How much home time will you need when you return?
How many miles or hours are you expecting per week?
How much do you expect to make per week (gross)?
If not, how long since leaving last employment?
123456789101112
Last school attended
List special courses or training that will help you as a driver
Address
zip
Position Held
Type Equip. Driven YesNo
Were you regulated by FMCSA during this job? YesNo
Areas Driven In YesNo
Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing? YesNo
Reasons for Leaving
Date
Type Equip. Driven YesNo Were you regulated by FMCSA during this job? YesNo Areas Driven In YesNo Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing? YesNo Reason for Leaving
Reason for Leaving
License Number
Type/Endorsements
Do you currently hold more than one valid license? YesNo
Have you ever been denied a license, permit or privilege to operate a motor vehicle? YesNo
Has any license, permit or privilege ever been suspended or revoked? YesNo
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Reg’s? YesNo
If answered Yes to any of the above questions, please give details: YesNo
City,State
Fatalities
Injuries
Head on Rear end etc
Location
Charge
Penalty
Class of Equipment
Type
List states operated in during last five years
List safe driving awards held & who presented by
It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty and reason for non-consideration or subsequent dismissal if hired or denial of authorization to drive. It is also agreed and understood that the motor carrier or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his/her furnishing such information. I understand that nothing contained in this application or in the granting of any interview or a road test is intended to create an employment contract between this company and myself, for either employment, authorization to driver, or for the providing of any benefits. I agree to furnish such additional information that may be necessary and complete such examinations as may be required to complete my application file including but not limited to a pre-employment negative urine test and successful completion of a human performance evaluation including a Department of Transportation Physical. No promises regarding employment or authorization to drive have been made to me, and no such promises exist unless specifically made by this Company in writing. It is agreed and understood that if qualified, hired or contract started, I may be on a probationary period during which time I may be disqualified without recourse. I understand employment or authorization to drive with this carrier is on an “at-will” basis that allows me to quit, be fired, or lease agreement revoked at any time with or without notice and with or without cause. 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 understand that all employment related language, including but not limited to “employer”, “employee”, and “employment” are used in conjunction with the requirements specified in FMCSR 391 and is not being construed as an offer of employment.
Signature of Applicant
Applicant Printed Name
Grafton Transit discloses to you that a consumer report, including an investigative report containing information as to your character, general reputation, personal characteristics, driving record, and mode of living may be obtained for qualification purposes as part of the pre-qualification background investigation and at any time during your relationship with the motor carrier. Should an investigation consumer report be requested you have the right to demand a complete and accurate disclosure of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act. Please sign below to signify receipt of the foregoing disclosure.
OFFICE USE ONLY
Qualification Date:
Failure to Qualify Date:
Staff Initials:
