COMPANY RITEWAY EXPRESS APPLICATION FOR EMPLOYMENT CITY, AND ZIP CODE BREVARD, NC 28712 NAME (FIRST) (MIDDLE) (MAIDEN NAME, IF ANY) (LAST) ADDRESS (STREET) (CITY) ( & ZIP CODE) OF BIRTH PREVIOUS THREE YEARS RESIDENCY (STREET) (CITY) ( & ZIP CODE) HOW LONG? # YEARS # YEARS # YEARS (ATTACH SHEET IF MORE SPACE IS NEEDED) LICENSE INFORMATION Section 383.21 FMCSR states No person who operates a commercial motor vehicle shall at any time have more than one driver s license. I certify that i do not have more than one motor vehicle license, the information for which is listed below. LICENSE NO. STREET ADDRESS 1106 ROSMAN HWY SOCIAL SECURITY NO. TYPE HIRE TELEPHONE NUMBER E-MAIL ADDRESS (STREET) (CITY) ( & ZIP CODE) (STREET) (CITY) ( & ZIP CODE) EXPIRATION CLASS OF EQUIPMENT STRAIGHT TRUCK TRACR AND SEMI-TRAILER TRACR - TWO TRAILERS OTHER S DRIVING EXPERIENCE TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.) ACCIDENT RECORD FOR PAST 3 YEARS OR MORE NATURE OF ACCIDENT (HEAD-ON, REAR-END,UPSET, ETC.) S NUMBER FATALITIES NUMBER INJURIES APPROX. NO. OF MILES (TAL) CHEMICAL SPILLS YES YES YES YES NO NO NO NO TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) S CONVICTED VIOLATION OF VIOLATION PENALTY (month/year) LOCATION (forfeited bond, collateral and/or points) A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO If yes, explain B. Has any license, permit or privilege ever been suspended or revoked? YES NO If yes, explain
EMPLOYMENT RECORD (ATTACH SHEET IF MORE SPACE IS NEEDED) Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the intial three years (total of ten years employment record). Must list the complete mailing address: street mumber and name, city, state and zip code LAST EMPLOYER: NAME ADDRESS PHONE POSITION HELD SALARY REASON FOR LEAVING ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE S (MONTH/YEAR) AND REASON Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40? YES NO SECOND LAST EMPLOYER: NAME ADDRESS PHONE POSITION HELD SALARY REASON FOR LEAVING ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE S (MONTH/YEAR) AND REASON Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40? YES NO THIRD LAST EMPLOYER: NAME ADDRESS PHONE POSITION HELD SALARY REASON FOR LEAVING ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE S (MONTH/YEAR) AND REASON Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40? YES NO BE READ AND SIGNED BY APPLICANT 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 offer of employment has been extended). I hereby realease employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in conection 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 49 CFR 391.23(d) and (e). I understand that I have the right to: Review information provided by current/previous employers; Have errors in the information correted 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 agree on the accuracy of the information. APPLICANT S SIGNATURE APPLICANT S SIGNATURE Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.
USE THIS SHEET FOR ADDITIONAL EMPLOYMENT HISRY INFORMATION (continued) NAME ADDRESS CITY CONTACT PERSON EMPLOYER WERE YOU SUBJECT THE FMCSRs WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO NAME ADDRESS CITY CONTACT PERSON EMPLOYER WERE YOU SUBJECT THE FMCSRs WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO NAME ADDRESS CITY CONTACT PERSON EMPLOYER WERE YOU SUBJECT THE FMCSRs WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO NAME ADDRESS CITY CONTACT PERSON EMPLOYER WERE YOU SUBJECT THE FMCSRs WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO NAME ADDRESS CITY CONTACT PERSON EMPLOYER ZIP PHONE NUMBER ZIP PHONE NUMBER ZIP PHONE NUMBER ZIP PHONE NUMBER ZIP PHONE NUMBER WERE YOU SUBJECT THE FMCSRs WHILE EMPLOYED? YES NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO *Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding. The Federal Motor Carrier Safety Regulatoins (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstte commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or mor, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding POSITION HELD POSITION HELD SALARY/WAGE REASON FOR LEAVING SALARY/WAGE POSITION HELD REASON FOR LEAVING SALARY/WAGE POSITION HELD REASON FOR LEAVING SALARY/WAGE POSITION HELD REASON FOR LEAVING SALARY/WAGE REASON FOR LEAVING Copyright 2005 J.J. KELLER & ASSOCIATES, INK., Neenah, WI USA (800)327-6868 www.jjkeller.com Printied in the United States
Company Name RiteWay Express, Inc. FAIR CREDIT REPORTING ACT DISCLOSURE MENT In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), your are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations. Print Name Date ID number
REQUEST FOR CHECK OF DRIVING RECORD NOTE MOR CARRIER: SEE BACK SIDE FOR S THAT ACCEPT THIS FORM RiteWay Express, Inc. I hereby authorize you to release the following informations to (Prospective Employer) for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. (Applicant s Signature) (Date)
Motor Vehicle Driver s CERTIFICATION OF COMPIANCE WITH DRIVER LICENSE REQUIREMENTS MOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placecarding. The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placecarding. DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain certain driver licensing requirements that you as a driver must comply with including the following: 1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator s license. 2) NOTIFICATIONS OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 391.15(b (2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver s license. In addition, Section 383.31 report it within 30 days to: 1) your employer motor carrier, and 2) the state that issued your license (if the employer and state must be in writing. 3) CDL DOMICILE REQUIREMENT: Section 383.23(a)(2) requires that your commercial driver s license be residence and to which you have the intention of returning whenever you are absent. If you establish a new domicile in another state, you must apply to transfer your CDL within 30 days. The following license is the only one I possess: Driver s License No. State Exp. Date DRIVER CERTIFICATION: I certify that I have read and understood the above requirements. Driver s Name (Printed): Driver s Signature: Date: Notes: (This form is not required for DOT compliance.)
PRE-EMPLOYMENT URINALYSIS CONSENT FORM I understand that as required by the Federal Motor Carrier Safety Regulations, Title 4 United States Code of Federal Regulations, Section 391.103, and company policy, all prospective drivers must submit to controlled substances test. A urine sample will be collected and tested for controlled substances. I also understand that if I test positive for use of controlled substances, I am not medically who will report whether the test results were negative or positive to RiteWay Express, Inc. month anniverserary. I hereby agree to submit to a drug screen urinalysis. Date
TAL APPLICANT SCREENING RELEASE In connection with my application for employment (including contract for services) with RiteWay Express, Inc. (Company) - any individual, organization, entity, agency, or other source providing information to above named employer and/or DAC Services from all claims and damages arising out of or relating I have been provided a copy of the summary of the rights of the consumer persuant to Fair Credit Reporting Act (FCRA), and have also been provided a disclosure that an investigative consumer report will be sought pursuant to FCRA. I hereby authorize and give my consent to the above company for the procurement of consumer report(s). If hired (or contracted), prucure consumer reports at any time during my employment (or contract) period. For purposes of gathering this information, I agree to supply the following information: Date of Birth _ Male Female Print Name Social Security No. Date
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