Driver Application Name* Email* Date Of Application MM slash DD slash YYYY Social Security No. :* Position(s) Applied For:* List your addresses of residency for the past 3 years:Current AddressStreet :* City :* State :* Zip Code :* Phone :* How Long? :* Previous AddressStreet : city : State : Zip Code : Phone : How Long? : Street : city : State : Zip Code : Phone : How Long? : Do you have the legal right to work in the United States?* Date of Birth: (Required of commercial drivers)* Can you provide proof of age?* Have you worked for this company before?* If yes, Dates:From MM slash DD slash YYYY To MM slash DD slash YYYY Rates of Pay Position Reason for leaving Are you now employed?* If not, how long since leaving last employment?Who referred you? Rate of pay expected* Is there any reason you might be unable to perform the functions of the job for which you have applied?Is there any reason you might be unable to perform the functions of the job for which you have applied?* Yes No If yes, explain if you wish.Driver Minimum Guidelines1. Drivers must be at least 24 years of age, with recent 3 years OTR verifiable Experience. 2. Drivers must furnish good phone numbers from all previous employers or carriers. 3. Drivers must hold CDL issued by their state of residence, and may only possess one license. The must also hold a valid DOT medical card by a DOT certified physician on the national registry. 4. Drivers can have no more than 2 moving violations, and no more than 2 preventable accidents in the previous 3 years. (no excessive speeding tickets and DUI’s or Felonies). 5. Drivers must have a regular service smartphone. (NO PREPAID CELL PHONE ALLOWED). 6. Owner-Operators must live within normal traffic lanes. 7. Drivers must be of good character and have a stable work history. They should be neat and clean and wear appropriate clothing. They must not wear clothing with obscene jesters or phrases, and obscene tattoos must be covered at all times. 8. All drivers will be required to pass a drug screen as required by the DOT. Drivers must not be disqualified under section 391.15 of Federal Motor Carrier Safety Regulations. 9. All drivers must be a citizen of the United States of America, or possess documentation showing their legal right to work, and legal residency in the United States. 10. Drivers must have personal transportation to and from work. 11. There will be a 90-day probationary period, during which time you will be evaluated on both work habits and attitude, in so far as how well you perform and get along with other owner operators, drivers, My-way employees, staff, customers and the public. 12. Independent Contractors lease deposit is $2500.00. This deposit is required for all leases. * I have read and understand each of the preceding statements. Employment History Past 10 Years Please give the following information regarding your current and previous employers. Start with the most recent. Use addition sheets if necessary and please explain any employment gaps.Employer Contact PhoneDate :From MM slash DD slash YYYY To MM slash DD slash YYYY Position Salary Address City State Zip Reason for LeavingWere 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 alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No Employers: Contact Phone Date From MM slash DD slash YYYY To MM slash DD slash YYYY Position Salary Address City State Zip Reason for LeavingWere 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 alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No Employers Contact Phone Date From MM slash DD slash YYYY To MM slash DD slash YYYY Position Salary Address: City : State: Zip: Reason for LeavingWere 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 alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No Employers: Contact: Phone: Date From MM slash DD slash YYYY To MM slash DD slash YYYY Position: Salary Address City: State: Zip: Reason for LeavingWere 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 alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No Employers: Contact: Phone: DateFrom MM slash DD slash YYYY To MM slash DD slash YYYY Position : Salary: Address City : State : Zip : Reason for Leaving: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 alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No Employers : Contact : Phone : Date From : MM slash DD slash YYYY To : MM slash DD slash YYYY Address: City: State: Zip: Reason for Leaving: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 alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No Employers : Contact : Phone : Date From : MM slash DD slash YYYY To : MM slash DD slash YYYY Position : Salary : Address: City : State : Zip: Reason for Leaving: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 alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No Employers : Contact : Phone : DateFrom : MM slash DD slash YYYY To : MM slash DD slash YYYY Position : Salary : Address : City : State : Zip : Reason for Leaving :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 alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No Please give the following information regarding your current employers and/or carriers. Start with the Most recent. Use the additional sheet if necessary and please explain any employment gaps.Truck Driving Applicants Previous Employment Reference Check Note: The sections below are for My Way Safety Department and your former employer. By signing this form, you authorize My Way to contact your former employer to collect this information. My Way Safety Department completesDriver Name : S.S.N# Company Name: Phone : FAX Former Employer Completes1] Was the applicants a : company driver sub-contractor owner-operator 2] What were the dates the applicant was employed or contracted to your company? Start : MM slash DD slash YYYY End : MM slash DD slash YYYY Start : MM slash DD slash YYYY End : MM slash DD slash YYYY 3] What type of equipment did he/she drive? Please check all that apply. Van Reefer Flat Tank 4] What types of products did this applicant transport? 5] What state(s) did the applicant operate? 6] Did the applicant have any accidents? Yes No If Yes, how many? PreventableNon-Preventable6a] Please give details:7] How was the applicants logs? Good Poor 7a] Did the applicant have hours of service violations? Please check all that apply. Yes No Out of service 7b] Did the applicant take DOT compliance seriously? Yes No 8] Did the applicant turn in all paper work neatly? Yes No 9] Did the driver abuse the equipment? Yes No 10] Did the driver have any cargo claims? Yes No 11] Was the driver on time for pick-ups and deliveries? Yes No 12] Why did the driver leave your company? Quit with notice Quit without notice Terminated 13] Is the driver eligible for rehire? Yes No upon review Section 382.405 (i) and (h). FMCSR requires we request and you provide specific information set forth below. Section 382.413 (e). The release of any information under this section may take the form of personal interview, telephone interviews, and letters of any method of transmitting this information that ensure confidentiality. Our facsimile (FAX) capability allows for such confidentiality.) Part 382.413 provides employee can no longer perform safety sensitive function if 14-days elapse and this information has not been received 1] Has this person, within the last 3 years, ever tested positive for a controlled substance? Yes No 2] Has this person, within the last 3 years, ever had a Breath Alcohol Concentration ( BAC) Final test of 0.04 BAC or greater? Yes No 3] Has this person, within the last 3 years, ever refused a required test for alcohol or Controlled substance? Yes No 4] Has this person violated other DOT drug/alcohol regulations? Yes No 5] Has this person tested positive on a pre-employment drug screen? Yes No 6] Has a previous employer indicated this person violated DOT drug/alcohol regulations? Yes No Third Choice 7] Failure to undertake or complete a rehabilitation program recommended by a professional? Yes No How are you returning this document to the requestor? FAX Mail Telephone Company Name Address City, State, Zip Phone Fax Person who completed this reference:Name Title Signature As required in Sub Section 382.405 (f) and (h), my signatureauthorizes you, my former Employer above Identified, to release and provide to the above named prospective company any and all information regarding my alcohol and controlled substance (drug) testing / training records, including Substance Abuse Professional (SAP) reports, Record of Employment, Accident and Cargo Claims from any and all of my current and / or former employers where I have worked during the past 10 years. APPLICANT COMPLETES - Driving Qualifications And Experience LICENSES HELD State License No Type Expiration Date MM slash DD slash YYYY State License No Type Expiration Date MM slash DD slash YYYY State License No Type Expiration Date MM slash DD slash YYYY State License No Type Expiration Date MM slash DD slash YYYY EQUIPMENT EXPERIENCETractor (Please complete if applicable) Equipment ClassTractor (Please complete if applicable) Equipment Class Equipment Type (Please check) For How Long ? Total Miles (Approx.) Tractor w/ Two-Trailer (Please complete if applicable) Equipment ClassTractor w/ Two-Trailer (Please complete if applicable) Equipment Class Equipment Type (Please check) For How Long ? Total Miles (Approx.) Straight Truck (Please complete if applicable) Equipment ClassStraight Truck (Please complete if applicable) Equipment Class Equipment Type (Please check) For How Long ? Total Miles (Approx.) Other (Please complete if applicable) Equipment ClassOther (Please complete if applicable) Equipment Class Equipment Type (Please check) For How Long ? Total Miles (Approx.) In what state have you operated in the past three years?*Have you ever had your license revoked or suspended ?* if so, when and where? Why ? (Please Explain)Have you ever been convicted of a felony?* if so, when and where? Why ? (Please Explain)Have you tested positive for a pre-employment or random Drug or Alcohol test in the past?* Yes No Accidents And Violations Date MM slash DD slash YYYY Injuries? Fatalities? Vehicle Type DescribeDate MM slash DD slash YYYY Injuries? Fatalities? Vehicle Type DescribeDate MM slash DD slash YYYY Injuries? Fatalities? Vehicle Type DescribeTRAFFIC CONVICTIONS IN THE PAST THREE YEARS (Not parking violations)Date MM slash DD slash YYYY Where? Violation Penalty Date MM slash DD slash YYYY Where? Violation Penalty Date MM slash DD slash YYYY Where? Violation Penalty Date MM slash DD slash YYYY Where? Violation Penalty Education And Training Please provide the following information about completed education, starting with the most recent.School or University Years Completed Field of Study Graduate? (Yes or No) When School or University Years Completed Field of Study Graduate? (Yes or No) When School or University Years Completed Field of Study Graduate? (Yes or No) When School or University Years Completed Field of Study Graduate? (Yes or No) When Have you ever served in the military? if so, when and what branch? Please list any training you have received that you think will benefit you in the position for which you are applying.Please provide three personal reference. These references should not be people related to you nor former supervisors.Name Years Known Phone Number Name Years Known Phone Number Name Years Known Phone Number Please use the following space to list any experience or knowledge you have, not mentioned previously, special accomplishments, or comments you would like us to consider.Carefully Read The Following - you will sign this application on the next page.By signing this statement, I certify that this employment application has been completed by me, and all of the entries provided are true, complete, and accurate, to the best of my knowledge. By signing below I also authorize this company to make such inquiries into my employment, financial, personal, or medical history as might be needed to make an employment decision. I understand that inquiries into my medical history are generally made after a job offer is made. I hereby release my former employers, healthcare providers and schools from any and all liability in making response to these inquiries and from releasing the requested information. In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to HireRight for the purpose of HireRight transmitting such records to the HireRight customer My-Way Transportation, Inc. I understand that information/documents released pursuant to this Part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/ or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation. If any company listed bel ow furnishes HireRight with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to HireRight, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years. By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; ( iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; ( v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.(Do not write below this line – Office use only) Interview Notes Date MM slash DD slash YYYY Interviewer Comment:Application Results Hired Rejected Hire Date MM slash DD slash YYYY Position If rejected, why? Date to Start: MM slash DD slash YYYY Starting Pay Comment:, complaints, Etc.Termination Date MM slash DD slash YYYY Quit Dismissed Why THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with My Way Transportation, Inc.("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Adminisfration (FMCSA). When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or elecfronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication. Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. The Prospective Employer cannot obtain background reports from FMCSA without your authorization. AUTHORIZATION If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize My Way Transportation, Inc.("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above. NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant's consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language. CAPTCHA
