DRIVER S/OWNER OPERATOR APPLICATION FOR EMPLOYMENT

Transcription

1 Tll: Tel: Fax: * * DRIVER S/OWNER OPERATOR APPLICATION FOR EMPLOYMENT Please read and sign page 6 befre cmpleting the fllwing applicatin fr emplyment. Please fill ut cmpletely, including wrk histry, d nt mark dwn see resume. (Cmpany Drivers d nt need t return this page with applicatin.) Including the fllwing infrmatin will assist the review prcess: Driver License cpy Driver Abstract (dated within the last 30 days) CVOR Abstract (dated within the last 30 days) Criminal search (dated within the last 6 mnths, Fast card is excepted in lieu) US Dcuments (if required) (Fast Card, Passprt r Enhanced Driver s license, US VISA, I94 card) OWNER OPERATOR ONLY: TRUCK: MAKE: MODEL; YEAR: COLOR: VIN # WEIGHT: FUEL CAPACITY: WHEELBASE: ENGINE: (INCH) 5 TH WHEEL HEIGHT: ABS: YES NO JAKE BRAKE: YES NO DO YOU OWN r LEASE THE TRUCK? IF LEASING FINANCING HELD BY: PAYMENTS: NAME ON OWNERSHIP: FLATBED DIVISION ONLY, TRAILER: MAKE: MODEL; YEAR: SUSPENSION: WEIGHT: LENGTH: INSIDE HEIGHT: ANNUAL SAFETY: (MM/DD/YY) VENTED: YES NO DO YOU OWN r FINANCE TRAILER? IF LEASING FINANCING HELD BY: PAYMENTS: UNTIL: PAPERWORK REQUIRED ONCE APPROVED: Prf f Disability (WSIB r Prf f private alternative) Bill f Sale r Lease Agreement Ownership Annual Inspectin Emissins Test 36 Day safety if name change r unfit n wnership. Business r Incrpratin papers. FORM1512

2 Tll: Tel: Fax: * * Name f Carrier: Travelers Transprtatin Services Inc. In cmpliance with Federal and Prvincial equal emplyment, pprtunity laws, qualified applicants are cnsidered fr all psitin withut required t race, clr, religin, sex, natinal rigin, age marital status, r nn-jb related disability, r any ther prtected grup status. Date f applicatin: Available t start: Psitin: OWNER OPERATOR COMPANY DRIVER O/O DRIVER FULL TIME PART TIME Divisin: VAN FLATBED INTERMODAL AREA: USA ONTARIO CANADA First Name Initial Last Name Huse/Apt # Street, City, Prvince, Pstal Cde ADDRESS(ES) FOR THE PAST THREE YEARS IF DIFFERENT FROM ABOVE: Huse/Apt # Street, City, Prvince, Pstal Cde Hw lng here Huse/Apt # Street, City, Prvince, Pstal Cde Hw lng here Hme phne#: Cell: Sin # Birth Date / / MM/DD/YR (required fr truck drivers) Driver s License # Prv Class Expiry (MM/DD/YR) Has yur license ever been suspended/revked/denied? Yes N Reasn: Hw many years f AZ Tractr Trailer driving experience: Legally eligible t wrk in Canada Yes N Can yu crss legally the US/Canadian Brder? Yes N Reasn: Have yu wrked fr us befre? Yes N T: Frm: Reasn fr leaving? Can yu drive a standard? Yes N Are yu bndable? Yes N Are yu currently emplyed? Yes N If n hw lng since leaving yur last emplyment: Is there any reasn yu might be unable t perfrm the functins f the jb fr which yu have applied? Yes N Explain: Hw did yu hear abut us? Wh referred yu? FORM1512 Page 1 f 6

3 Tll: Tel: Fax: * * List yur emplyment histry fr the past 10 years starting with the mst current emplyer. All time fr the past 10 years must be accunt fr even if yu were unemplyed r in training/schl. Cmpany Start Date End Date Address City Prvince Pstal cde: Psitin Full Time Part Time Salary/Wage: Type f Truck Operated Straight Truck Tractr Trailer Standard Transmissin Aut Transmissin Bunk Truck Day Cab Type f Trailer Hauled 48/53 ft Van Reefer Flatbed Trains Multi Axle Lift Axle Steer Axle Cntainers Where did yu run? Lcal Only Quebec Western Canada Eastern USA Mid West USA Western USA Muntains Were yu subject t the FMCSR s while emplyed here? Yes N Was yur jb designated as a safety-sensitive functin in any DOT- regulated mde subject t the drug and alchl testing requirements f 49 CFR Part 40? Yes N Cntact Persn: Phne # Fax # Accunt fr Perid between Jbs- Include reasn & dates (mnth/year) : Cmpany Start Date End Date Address City Prvince Pstal cde: Psitin Full Time Part Time Salary/Wage: Type f Truck Operated Straight Truck Tractr Trailer Standard Transmissin Aut Transmissin Bunk Truck Day Cab Type f Trailer Hauled 48/53 ft Van Reefer Flatbed Trains Multi Axle Lift Axle Steer Axle Cntainers Where did yu run? Lcal Only Quebec Western Canada Eastern USA Mid West USA Western USA Muntains Were yu subject t the FMCSR s while emplyed here? Yes N Was yur jb designated as a safety-sensitive functin in any DOT- regulated mde subject t the drug and alchl testing requirements f 49 CFR Part 40? Yes N Cntact Persn: Phne # Fax # Accunt fr Perid between Jbs- Include reasn & dates (mnth/year) : FORM1512 Page 2 f 6

4 Tll: Tel: Fax: * * Cmpany Start Date End Date Address City Prvince Pstal cde: Psitin Full Time Part Time Salary/Wage: Type f Truck Operated Straight Truck Tractr Trailer Standard Transmissin Aut Transmissin Bunk Truck Day Cab Type f Trailer Hauled 48/53 ft Van Reefer Flatbed Trains Multi Axle Lift Axle Steer Axle Cntainers Where did yu run? Lcal Only Quebec Western Canada Eastern USA Mid West USA Western USA Muntains Were yu subject t the FMCSR s while emplyed here? Yes N Was yur jb designated as a safety-sensitive functin in any DOT- regulated mde subject t the drug and alchl testing requirements f 49 CFR Part 40? Yes N Cntact Persn: Phne # Fax # Accunt fr Perid between Jbs- Include reasn & dates (mnth/year) : Cmpany Start Date End Date Address City Prvince Pstal cde: Psitin Full Time Part Time Salary/Wage: Type f Truck Operated Straight Truck Tractr Trailer Standard Transmissin Aut Transmissin Bunk Truck Day Cab Type f Trailer Hauled 48/53 ft Van Reefer Flatbed Trains Multi Axle Lift Axle Steer Axle Cntainers Where did yu run? Lcal Only Quebec Western Canada Eastern USA Mid West USA Western USA Muntains Were yu subject t the FMCSR s while emplyed here? Yes N Was yur jb designated as a safety-sensitive functin in any DOT- regulated mde subject t the drug and alchl testing requirements f 49 CFR Part 40? Yes N Cntact Persn: Phne # Fax # Accunt fr Perid between Jbs- Include reasn & dates (mnth/year) : FORM1512 Page 3 f 6

5 Tll: Tel: Fax: * * Cmpany Start Date End Date Address City Prvince Pstal cde: Psitin Full Time Part Time Salary/Wage: Type f Truck Operated Straight Truck Tractr Trailer Standard Transmissin Aut Transmissin Bunk Truck Day Cab Type f Trailer Hauled 48/53 ft Van Reefer Flatbed Trains Multi Axle Lift Axle Steer Axle Cntainers Where did yu run? Lcal Only Quebec Western Canada Eastern USA Mid West USA Western USA Muntains Were yu subject t the FMCSR s while emplyed here? Yes N Was yur jb designated as a safety-sensitive functin in any DOT- regulated mde subject t the drug and alchl testing requirements f 49 CFR Part 40? Yes N Cntact Persn: Phne # Fax # WHY DID YOU LEAVE THIS POSITION? Accunt fr Perid between Jbs- Include reasn & dates (mnth/year) : Cmpany Start Date End Date Address City Prvince Pstal cde: Psitin Full Time Part Time Salary/Wage: Type f Truck Operated Straight Truck Tractr Trailer Standard Transmissin Aut Transmissin Bunk Truck Day Cab Type f Trailer Hauled 48/53 ft Van Reefer Flatbed Trains Multi Axle Lift Axle Steer Axle Cntainers Where did yu run? Lcal Only Quebec Western Canada Eastern USA Mid West USA Western USA Muntains Were yu subject t the FMCSR s while emplyed here? Yes N Was yur jb designated as a safety-sensitive functin in any DOT- regulated mde subject t the drug and alchl testing requirements f 49 CFR Part 40? Yes N Cntact Persn: Phne # Fax # WHY DID YOU LEAVE THIS POSITION? Accunt fr Perid between Jbs- Include reasn & dates (mnth/year) : FORM1512 Page 4 f 6

6 Tll: Tel: Fax: * * Have yu had Dangerus Gds Training in the last 3 years? Yes N Expiry Date: Shw special curses r training that will help yu as a driver: Which safe driving award d yu hld and frm whm: Educatin: Highest Grade Cmpleted Cllege Name University Name Driver Training: Name f Schl Curse Date: LIST ANY ACCIDENTS YOU HAVE HAD IN THE LAST 3 YEARS Date Descriptin Fines / Charges Amunt CVOR Affected TICKETS WITHIN THE LAST 3 YEARS (CAR OR TRUCK ) Date Descriptin Fines / Charges Amunt CVOR Affected DRIVING EXPERIENCE: Equipment Class Van/Reef/Van/Tank Etc T Frm Apprx Miles Straight Truck Tractr Semi Trailer Tractr with Dubles Tractr with Tanks In accrdance with 49 CFR have yu tested psitive, r refused t test, n any pre-emplyment drug r alchl test administrated by an emplyer t which yu applied fr, but did nt btain, safety-sensitive transprtatin wrk cvered by DOT agency drug and alchl testing rules during the past three years? Yes N This certifies that this applicatin was cmpleted by me, and that all entries n it and infrmatin in it are true and cmplete t the best f my knwledge. Applicant s Signature: Date: Applicant s Name Print: FORM1512 Page 5 f 6

7 Tll: Tel: Fax: * * REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYERS Driver Please Read, Sign, and Date at Bttm f Page TO BE READ AND SIGNED BY THE APPLICANT I authrize yu t make such investigatins and inquiries f my persnal, emplyment, financial and/r medical histry and ther related matters as may be necessary in arriving at an emplyment/cntract f service decisin. (Generally, inquiries regarding medical histry will be made nly if and after a cnditin ffer f emplyment/cntract f service has been extended.) I hereby release emplyers, schls, health care prviders and ther persns frm all liability in respnding t inquiries and releasing infrmatin in cnnectin with my applicatin. FMSCR In the event f emplyment, I understand that false r misleading infrmatin given in my applicatin r interview(s) may result in discharge. I understand, als, that I am required t abide by all rules and regulatins f Travelers Transprtatin Services/Travelers Grup f Cmpanies. I understand that infrmatin I prvide regarding current and/r previus emplyers may be used, and thse emplyer(s) will be cntacted, fr the purpse f investigating my safety perfrmance histry as required by 49CFR (d) and (e). I understand that I have the right t: Review infrmatin prvided by previus emplyers; Have errrs in the infrmatin crrected by previus emplyers and fr thse previus emplyers t resend the c crrected infrmatin t the prspective emplyer; and Have a rebuttal statement attached t the alleged errneus infrmatin, if the previus emplyer(s) and I cannt agree n the accuracy f the infrmatin. Cnsent fr infrmatin frm Previus Emplyer: I, hereby authrize yu t release persnal, emplyment, financial and/r medical infrmatin t Travelers Transprtatin Services/Travelers Grup f Cmpanies fr purpses f investigatin as required by Sectin f the Federal Mtr Carrier Safety Regulatins. Yu are released frm any and all liability that may result frm furnishing such infrmatin. In accrdance with 49 CFR (f). by my signature belw I authrize yu and/r yur Third Party Administratr t release any and all infrmatin regarding drug and alchl testing dne n myself including any and all infrmatin n this frm and respnses t questins set ut n this frm, while in yur emplyment, acting as yur agent, under cntract with yu, r acting as yur representative in any capacity during the preceding three years frm the abve date. This infrmatin is t be released t the prspective emplyer named belw and/r t their Third Party Administratr. Applicant s Signature SIN# Applicant s Name: Date FORM1512 Page 6 f 6