DRIVER’S APPLICATION

(Answer all questions)

 

In compliance with Federal and State equal employment opportunity laws, qualified applicants

are considered for all positions without regard to race, color, creed, religion, sex, national origin

age, marital status, or non-job related disability.

 

Date of application:  

 

 

 

Name  Social Security No. (No dashes)

Last First Middle

 

Address  

                    Street                                                                     City                                           State                           Zip Code

 

Home Phone Cell Phone(s)

 

Address                      How Long

For Past      street city state zip

Three     

Years                            How Long

                     street city state zip

 

Do you have the legal right to work in the United States? Date of Birth

                                                                                                                                     (Required for Truck Drivers)

 

Have you worked for this company before?  Where?

 

Dates:  From  to  Reason for leaving?

 

Are you employed now?  If not, how long since leaving last employment?

 

Who referred you?

 

IN THE LAST FIVE (5) YEARS:

1. Have you ever tested positive for a pre-employment drug and/or alcohol screen at a company for which you applied? ………	Yes  No
2. Have you ever been denied a license, permit or privilege to operate a motor vehicle? ………	Yes  No
3. Has any license, permit or privilege ever been suspended or revoked? ………	Yes  No
4. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description) ………	Yes  No
5. Have you ever been convicted of a felony? ………	Yes  No
IF THE ANSWERS TO 1, 2, 3, 4 or 5 IS “YES”, GIVE DETAILS.

EMPLOYMENT HISTORY

All driver applicants to drive in Interstate Commerce must provide the following information on all employers during the preceding 3 years.  Applicants to drive a commercial motor vehicle* in interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.

(NOTE:  List employers in reverse order starting with the most recent.  Add another sheet as necessary.)

EMPLOYER	DATES
NAME	From	To
ADDRESS	Position held
CITY  STATE  ZIP	Type of Trailer pulled
PHONE	Reason for leaving
Were you subject to FMCSR's while employed?        Was this a Safety Sensitive function?
EMPLOYER	DATES
NAME	From	To
ADDRESS	Position held
CITY  STATE  ZIP	Type of Trailer pulled
PHONE	Reason for leaving
Were you subject to FMCSR's while employed?        Was this a Safety Sensitive function?
EMPLOYER	DATES
NAME	From	To
ADDRESS	Position held
CITY  STATE  ZIP	Type of Trailer pulled
PHONE	Reason for leaving
Were you subject to FMCSR's while employed?        Was this a Safety Sensitive function?
EMPLOYER	DATES
NAME	From	To
ADDRESS	Position held
CITY  STATE  ZIP	Type of Trailer pulled
PHONE	Reason for leaving
Were you subject to FMCSR's while employed?        Was this a Safety Sensitive function?
EMPLOYER	DATES
NAME	From	To
ADDRESS	Position held
CITY  STATE  ZIP	Type of Trailer pulled
PHONE	Reason for leaving
Were you subject to FMCSR's while employed?        Was this a Safety Sensitive function?
EMPLOYER	DATES
NAME	From	To
ADDRESS	Position held
CITY  STATE  ZIP	Type of Trailer pulled
PHONE	Reason for leaving
Were you subject to FMCSR's while employed?        Was this a Safety Sensitive function?

 

* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

 

 

 

 

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED).

DATES	NATURE OF ACCIDENT (HEAD ON, REAR END, ROLLOVER, ETC)	FATALITIES	INJURIES
Last accident
Next previous
Next previous

 

 

 

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3  YEARS (OTHER THAN PARKING VIOLATIONS).

LOCATION	DATE	CHARGE	PENALTY

(ATTACH SHEET IF MORE SPACE IS NEEDED)

 

 

 

EDUCATION

HIGHEST ELEMENTARY GRADE COMPLETED:  1 2 3 4 5 6 7 8     HIGH SCHOOL:  1 2 3 4    COLLEGE:  1 2 3 4

 

LAST SCHOOL ATTENDED 

                                                   (Name)                                                                       (City)

 

 

 

EXPERIENCE AND QUALIFICATIONS  - DRIVER

DRIVERS LICENSE	STATE	LICENSE NO.	TYPE	ENDORSEMENTS	EXPIRATION

 

 

DRIVING EXPERIENCE

	# Years Experience	Area driven: (West, Southeast, etc.)
VAN
REEFER
FLATBED

General Questionaire

Very Imporant! Please answer all questions.

Are you looking to lease on your truck?

If so, will you be driving your truck?

What is the year and make of the truck?

Are you also leasing on a trailer?

Do you have your own tractor tag or will you need assistance in obtaining a company tractor tag?

 

OR

 

Are you planning to participate in our purchase program?

 

OR

 

Do you want to drive for an Owner/Operator?

If so, whom?

Where did you find out about our company?

If you heard about us from a driver or employee of JRS/JAS, please tell us who.

What kind of trailer are you planning to pull with our company?
Dry Van  Refrigerated Trailer  Flat Bed

What office, if any, have you talked with about running for?

(updated 4/2/07)

By selecting this checkbox I am agreeing to terms as described below.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.  I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment/lease decision.  (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.)  I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.  PLEASE NOTE:  A driver has the right to review and refute any information received.  Any rebuttals must be received within 30 days of notification and in writing.  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.

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