Employment Form

Employment Application

TO BE READ AND SIGNED BY APPLICANT

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 previous employers;
  • Have errors in the information corrected 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.
MM slash DD slash YYYY
Name

List your addresses of residency for the last 3 years.

Current Address
Previous Addresses
Street
City/St/Zip
How Long YRs?
 
MM slash DD slash YYYY
(Required for Commercial Drivers)
Max. file size: 2 MB.
MM slash DD slash YYYY
MM slash DD slash YYYY
Can you perform, with or without reasonable accommodation, the essential functions of the job?
See pages 9-12 of this application.

EMPLOYMENT HISTORY

All applicants desiring to drive a commercial motor vehicle (CMV), for intrastate or interstate commerce, must provide an additional 7 years of information on those employers for whom the applicant operated a CMV.
(NOTE: List employers in reverse order, starting with the most recent. Add another page if necessary)
MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs WHILE EMPLOYED
WAS YOUR JOB DESIGNATED AS A SAFETY- SENSITIVE FUNCTION IN ANY DOR- REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART40?
MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs WHILE EMPLOYED
WAS YOUR JOB DESIGNATED AS A SAFETY- SENSITIVE FUNCTION IN ANY DOR- REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART40?
MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs WHILE EMPLOYED
WAS YOUR JOB DESIGNATED AS A SAFETY- SENSITIVE FUNCTION IN ANY DOR- REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART40?
MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs WHILE EMPLOYED
WAS YOUR JOB DESIGNATED AS A SAFETY- SENSITIVE FUNCTION IN ANY DOR- REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART40?
MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Were you subject to the FMCSRs WHILE EMPLOYED
WAS YOUR JOB DESIGNATED AS A SAFETY- SENSITIVE FUNCTION IN ANY DOR- REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART40?

ACCIDENT RECORD: FOR THE PAST 3 YEARS (ATTACH SHEET IF MORE SPACE IS NEEDED

(OTHER THAN PARKING VIOLATIONS) IF NONE… WRITE NONE ATTACH SHEET IF MORE SPACE IS NEEDED
LAST ACCIDENT
(Head-On, Rear-end, Roll over ,ect)
NEXT PREVIOUS
(Head-On, Rear-end, Roll over ,ect)
NEXT PREVIOUS
(Head-On, Rear-end, Roll over ,ect)

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE LAST 3 YEARS

(OTHER THAN PARKING VIOLATIONS) IF NONE… WRITE NONE
ATTACH SHEET IF MORE SPACE IS NEEDED
List
LOCATION
DATE
CHARGE
PENALTY
 

EXPERIENCE AND QUALIFICATIONS- DRIVER

DRIVER LICENSES OR PERMITS HELD IN THE PAST 3 YEARS
STATE
LICENSE NO.
CLASS
ENDORSEMENT
EXPIRES
 

DRIVING EXPERIENCE

STRAIGHT TRUCK (CLASS OF EQUIPMENT)
CIRCLE TYPE OF EQUIPMENT
MM slash DD slash YYYY
MM slash DD slash YYYY
TRACTOR AND SEMI TRAILER (CLASS OF EQUIPMENT)
CIRCLE TYPE OF EQUIPMENT
MM slash DD slash YYYY
MM slash DD slash YYYY
TRACTOR- TWO TRAILERS (CLASS OF EQUIPMENT)
CIRCLE TYPE OF EQUIPMENT
MM slash DD slash YYYY
MM slash DD slash YYYY
TRACTOR- THREE TRAILERS (CLASS OF EQUIPMENT)
CIRCLE TYPE OF EQUIPMENT
MM slash DD slash YYYY
MM slash DD slash YYYY
MOTORCOACH- SCHOOL BUS 8+ (CLASS OF EQUIPMENT)
MM slash DD slash YYYY
MM slash DD slash YYYY
MOTORCOACH- SCHOOL BUS 15+ (CLASS OF EQUIPMENT)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

EXPERIENCE AND QUALIFICATIONS- OTHER

MILITARY RECORD & BRANCH OF SERVICE

MM slash DD slash YYYY
MM slash DD slash YYYY
Retired:
Present military affiliation (circle one)

EDUCATION

SCHOOL
HIGH SCHOOL:
COLLEGE:
This certifies that this application was completed by me, and that all the entries on it and information in it are true and complete to the best of my knowledge.
MM slash DD slash YYYY

I have read and understood the preceding Disclosure to Customer, Under the Fair Credit Reporting Act, FCRA, 15 U.S.C. 1681 et seq., the regulations applicable to federal Department of Transportation's Federal Motor Carriers Safety Administration including The Americans with Disability Act and all other applicable federal state and local laws. Hereby authorize and permit the above named company to obtain information about me where permitted which may pertain to my employment records driving history, driving performance and safety history, criminal history, credit history, civil records, workers compensation, alcohol and drug testing, verification of my academic and or professional credentials, and information and copies of documents from any military service records.

I understand an investigation consumer report may include information as to my character, general reputation, personal characteristics, an motive living that may be obtained by interviews with individuals who may have knowledge concerning any such items of information. I authorized information to be obtained from my former employers to satisfy driver qualification regulations.

DOT Drivers: I understand that title 49 of the federal code of regulations requires my perspective employer and or its agents may contact all former employers of a driver within the last three years under the regulations of the Department of Transportation. Information such as dates of employment position accident history as well as information pertaining to my drug and alcohol test history maybe requested from each employer in accordance with Section 391.23 and CFR 40.25.

By signing below I consent to and authorize the gathering of this information by my perspective employer or employer and those who my perspective employer or employer has engaged to request an obtain this information including former employers, and or from a consumer reporting agency, such as iiX, a Verisk Analytic Business.

I understand and acknowledge that the information provided in the consumer report or investigative Consumer Reports may assist my employer or perspective employer to make a determination regarding my suitability as an employee.

Further I understand that under FCRA, in the event of adverse action, I may request a copy of any consumer report from the consumer reporting agency that compiled the report , after I have provided proper identification.

I agree that a copy of this authorization has the same effect as the original. Where permitted, this authorization shall remain in effect over the course of my employment and reports may be ordered periodically during the course of my employment.

Petroleum Tanker and Tank Truck Driver Job Description and Requirements

PULL2 Driver must be able to uncouple the 5th wheel using a force of 80 lbs. (1x/shift)
PULL3 Pull 1 3/8” hose and nozzle for a distance of over 100’, around equipment and perform fueling. Weight and force required of 80 lbs. depending on slope.
PUSH1 Driver must be able to push hood back up from 5 feet up to 6 feet to secure the hood using 30 lbs. of force. (2x/shift)
PUSH/PULL Driver must be able to connect delivery hose to the product valve using 90 lbs. of force. (20x/shift)
PUSH/PULL Driver must lift and manipulate a counter weight or spring resistant terminal loading rise and connect to the trailer. Movement and position requires bending at the waist and rotating loading head under the trailer. Potentially this activity is 12x/shift and risers require 100 lbs. of force.
CLIMB1 Driver must be able to climb up onto the 1st tractor step,transferring his/her own body weight from 0”-17.5” while holding on to hand rail at 62”.
(20x/shift).
CLIMB2 Driver must be able to climb down the tractor steps while controlling his body weight from 17.5”-0” while holding onto hand rail at 62”. (20x/shift)
CLIMB3 Driver must be able to climb up 10 ladder rungs that are 10” in height on the rear of the trailer. (1x/shift)
CLIMB4 Drivers may be required to climb unguarded ladders attached to above ground tanks, at heights over 15’.

Petroleum Tanker and Tank Truck Driver Job Description and Requirements

COUPLE1 Driver must be able to grip 3” circumference to turn valves. (10x/shift)
COUPLE2 Driver must be able to lock hose ears using a grip force of 50 lbs. (32x/shift)
COUPLE3 Driver must be able to pull on lever of product valve using a force of 15 lbs. (20x/day)
COUPLE4 Driver must be able to turn belly valve using a force of 15 lbs. (20x/day)
LIMITED HEAD ROOM Driver must be able to gain access under the trailer 28” and be able to cross underneath that trailer for a distance of 92”. (1x/shift)
POSTURE1 Driver must be able to walk or crawl on his hands and knees under the trailer up to 30 feet. (2x/shift)
POSTURE2 Driver must be able to get down to the level of the ground and reach 4” below the ground’s surface to attach and detach fuel hose. (20x/shift)
STAND1 Driver must be able to stand for prolonged periods of time during a shift. Up to 90 minutes on asphalt, concrete, gravel or unimproved surfaces.
SIT Driver must be able to sit for prolonged periods of time during a shift.

Petroleum Tanker and Tank Truck Driver Job Description and Requirements

TEMPERATURE/WEATHER: Driver must be able to tolerate working with outside temperatures as needed. Occupation requires working in all weather conditions to include unshaded full sunlight, full downpour rain, below freezing temperatures and high heat and humidity.
LIMITED LIGHT: Drivers are required to perform all aspect of the occupation in very limited light, both natural and man-made. Limit light areas can be accompanied with uneven terrain and wet, muddy conditions with tripping hazards.