YES NO 1. Do you have a Valid Class A CDL Texas Drivers License? 2. Have you ever been cited for reckless driving?

Transcription

1 DRIVER PRELIMINARY QUALIFICATION SHEET DRIVER S NAME: YES NO 1. Do you have a Valid Class A CDL Texas Drivers License? 2. Have you ever been cited for reckless driving? 3. Have you ever been arrested for DUI in the last 5 years? 4. Have you ever been charged with a Hit and Run? 5. Have you ever been cited with Excessive Speeding? 6. Has your License ever been Revoked or Suspended in the last 3 years? 7. Do you have (3) or more Moving Violations in the last 12 months? 8. Do you have more than (2) Violations in the last 12 months? 9. Do you have any Accidents in the last 5 years? 10. Have any accidents been your fault? 11. Do you have 3 years OTR driving Tractor/Trailer experience? 12. How many employers have you had in one year? 13. What have you hauled? 14. Are you 25 years of age or older? 15. Are you willing to take a Drug Screen Test today? 16. Are you willing to take a DOT physical at your expense? 17. Do you have any Physical conditions that will restrict you from performing the job you are applying for? 18.) Have you been convicted of a felony in the last 7 years? Upon qualification, a copy of your social security, medical card and driver s license must be submitted.

2 DRIVER APPLICATION ALL QUESTIONS MUST BE COMPLETED. Name: Socual Security Number: Address: City: State: Zip: Phone#: ( ) Date of Birth: License #: Notify In Case of Emergency: Phone #: ( ) Address: City: State: Zip: Have you ever applied here before? Yes No Date: Referred By: RESIDENCE ADDRESSES LIST RESIDENCE ADDRESSES FOR THE PAST 3 YEARS. Address City State Zip Address City State Zip EDUCATION Have you attended Truck Driving School? Yes No Graduation Date: Name: Location: Circle highest grade completed: Grade School High School College Other: Last School Attended: Did You Graduate? Yes No Other Education:

3 EDUCATION Type of Equipment Driven Length of Experience Approximate Total # of Miles Straight Truck Tractor & Semi Trailer Truck & Full Trailer Other In What States Have You Driven Regularly? What Awards Do You hold for Safe Driving? WORK EXPERIENCE Showing the past three (3) years of contracted work, and/or commercial driving experience for the past (10) years, list below the past and present contractors beginning with your present or most recent. All time must be accounted for including unemployment.

4 WORK EXPERIENCE

5 WORK EXPERIENCE

6 ACCIDENTS List and explain in detail, giving dates and location of all accidents that you have been involved in during the past five (5) years, in any type of vehicle, regardless of whether you feel they were chargeable or nonchargeable. FAILURE TO LIST ALL ACCIDENTS MAY RESULT IN YOUR DISQUALIFICATION. IF YOU HAVE HAD NO ACCIDENTS IN THE PAST FIVE (5) YEARS WRITE NONE. Date: Type of Vehicle: Whose Fault: Fatalities: Yes No Injuries: Yes No Dollar Amount of Damage: Date: Type of Vehicle: Whose Fault: Fatalities: Yes No Injuries: Yes No Dollar Amount of Damage: Date: Type of Vehicle: Whose Fault: Fatalities: Yes No Injuries: Yes No Dollar Amount of Damage: Date: Type of Vehicle: Whose Fault: Fatalities: Yes No Injuries: Yes No Dollar Amount of Damage:

7 TRAFFIC VIOLATIONS I certify that the following is a true and complete list of all traffic violations other than parking violations) for which I have been convicted or forfeited bond or collateral during the past five- (5) years. FAILURE TO LIST ALL TRAFFIC VIOLATIONS MAY RESULT IN YOUR DISQUALIFICATION. IF YOU HAVE HAD NO TRAF- FIC VIOLATIONS IN THE PAST FIVE (5) YEARS WRITE NONE. Traffic Convition(s) Describe Date City and State Penalty REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER I hereby authorize you to release the following information to Sunline Commercial Carriers, Inc. As per the U.S. Department of Transportation regulations (49 CFT Part 40) requires companies that are regulated by the DOT to answer questions regarding individuals who were employed by them in a DOT safety sensitive function within the 3 previous years. I hereby release from any and all liability which may result from furnishing such information. Print Name of Applicant Signature Social Security No. Date Dear Motor Carrier Motor Carrier Name The above named individual has made an application to this company for position of driver. They also state that he/she was employed by you as a driver. Please fill out the following information: Employment dates were from to from to Thank you for your time and consideration to this matter. If you have any questions, you may reach me at , ext. 12, please fax information to Respectfully, Peggy Rosales, Vice President of Safety Sunline Commercial Carriers, Inc.

8 DRUG AND ALCOHOL INQUIRY DATE IF YES In the past 3 years did the applicant have any DOT drug and alcohol violations? ( ) Yes ( ) No Has this person ever tested positive for a controlled substance? ( ) Yes ( ) No Has this person ever had an alcohol test with result of 0.04 or greater? ( ) Yes ( ) No Has this person ever refused a required test for alcohol or drugs? ( ) Yes ( ) No Has this person violated other DOT drug/alcohol regulations? ( ) Yes ( ) No If applicant was employed as a driver, please give correct dates of employment: From: to: From: to: Type of equipment: Area of operation: Tractor/Trailer Straight Truck Flatbed Gravel Truck Local Texas Only 48 States Other Number of Accidents: # of Chargeable # of Non Chargeable Brief description of accidents:. Was this employee s conduct: Above Average Average Below Average Poor Did the employee have any recurring log book issues? Did the employee have any recurring problems with traffic tickets: Yes No Yes No Did this employee Resigned Discharged Laid Off Would you re-hire this employee: Yes No Upon Review If No, why Signature or Name of Person providing information Title Date

9 PRE-EMPLOYMENT URINALYSIS NOTIFICATION The Federal Motor Carrier Safety Regulations, Section pre-employment testing requirements, apply to driver - applicants of this company. If hired, you will be subject to laws requiring additional DATE controlled IF YES substance and alcohol testing on you under numerous situations including but not limited to: Post Accident Section , Return to Duty Section , Random Section , Reasonable Suspicion Section and Follow-up Section Pre-employment testing requirements: A. Prior to the first time a driver performs a safety sensitive function for the motor carrier, the driver shall undergo testing for controlled substances as a condition of being hired. B. A driver-applicant shall submit to controlled substance testing as a pre-qualification condition. C. Prior to collection of urine sample under subpart, a driver applicant shall be notified that the sample will be tested for the presence of controlled substances. As a condition of my employment, I agree to the urine sample collection and controlled substance testing. I understand a positive test for controlled substances based on the urinalysis test will medically disqualify me from the operation of a commercial motor vehicle for this company. The Medical Review Officer will maintain the results of the urinalysis test. Negative and positive results will be reported to the company. My written authorization is required for the Urinalysis test results to be given to other parties. I have read and understand the above conditions for the Pre-Employment Urinalysis Notification. Print Applicants Name Signature of Applicant Date