Apply Application with Shelba D. Johnson Trucking, Inc.

Home | Site Map | Express Check | Customer Login | Warehouse Login

About Us

Services

Clients

Welcome to Shelba D Johnson Trucking

SDJ Trucking Charities:

Employment

Driver Employment Application

Required fields are marked with an * asterisk.

Signature of Applicant* (Typing Name Signifies Signature)

09/08/2010
Date*

Name:			Phone:*
First*	Middle*	Last*	Cell:*

*Current Address:

Street*

City / State / Zip*

How Long*

*If at the above residence less than three years, list below all residences for the past three years. Attach a separate sheet if necessary.

Previous Address 1:

Street*

City / State / Zip*

How Long*

Previous Address 2:

Street*

City / State / Zip*

How Long*

Previous Address 3:

Street*

City / State / Zip*

How Long*

Previous Address 4:

Street*

City / State / Zip*

How Long*

Previous Address 5:

Street*

City / State / Zip*

How Long*

Position Applying for:* Temporary Part Time Full Time

Who referred you? Rate of pay expected?*

Have you worked for this company before? YesNo Dates:

From
month/year

To
month/year

Where? Rate of Pay Position

Reason for Leaving

Names of any relatives employed by this company

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

EDUCATION

Select highest grade completed: 123456789101112 College: 1234Higher

Last School attended?

Name

Address

GENERAL

Have you ever been bonded? YesNo Name of bonding company?
(Answer only if a job requirement)

Have you ever been convicted of a felony? YesNo
If yes, please explain fully below. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.

Have you ever worked for this company under another name? YesNo If, so, under what name?

EMPLOYMENT RECORD

The U.S. Department of Transportation requires that driver applicants show all employment for last three years. Effective July 1987 they
also show commercial driver employment for the seven years immediately preceeding this three year period. §391.21 (b)(10),(11).

   Current Employer:    Supervisor Name:
   Address:*    Phone:
   City:*    State:*    Zip:      Fax:
   Was this position under FMCSA regulations? YesNo
   Where you in an ACTIVE drug and alcohol testing program? YesNo
   Position Held:    From:*    To:*    Salary:
   Reason for Leaving:

   Second Employer:    Supervisor Name:
   Address:*    Phone:
   City:*    State:*    Zip:      Fax:
   Was this position under FMCSA regulations? YesNo
   Where you in an ACTIVE drug and alcohol testing program? YesNo
   Position Held:    From:*    To:*    Salary:
   Reason for Leaving:

   Third Employer:         Supervisor Name:
   Address:*    Phone:
   City:*    State:*    Zip:      Fax:
   Was this position under FMCSA regulations? YesNo
   Where you in an ACTIVE drug and alcohol testing program? YesNo
   Position Held:    From:*    To:*    Salary:
   Reason for Leaving:

   Fourth Employer:       Supervisor Name:
   Address:*    Phone:
   City:*    State:*    Zip:      Fax:
   Was this position under FMCSA regulations? YesNo
   Where you in an ACTIVE drug and alcohol testing program? YesNo
   Position Held:    From:*    To:*    Salary:
   Reason for Leaving:

   Fifth Employer:           Supervisor Name:
   Address:*    Phone:
   City:*    State:*    Zip:      Fax:
   Was this position under FMCSA regulations? YesNo
   Where you in an ACTIVE drug and alcohol testing program? YesNo
   Position Held:    From:*    To:*    Salary:
   Reason for Leaving:

DRIVER EXPERIENCE & QUALIFICATION

Date of Birth* The U.S. Department of Transportation requires that driver applicatnts state their date of birth §391.21 (b)(2).
(month/day/year)*

Social Security Number*

License

Driver Licenses held in past 3 years must be shown	STATE	LICENSE NO.	TYPE	EXPIRATION DATE

A.	Have you ever had any type of motor vehicle license suspended or revoked, or ever been denied a license, permit of privilege to operate a motor vehicle?	YesNo
B.	Do you have a pending charge or past conviction for driving while intoxicated?	YesNo
C.	Do you have a pending charge or past conviction for possession of a controlled substanse?	YesNo
D.	Have you ever been refused auto liability insurance?	YesNo
E.	Do you have a pending charge or conviction for any misdermeanor or felony offense?	YesNo
	If you answered "yes" to A, B, C, D or E, give full details below.

Driving Experience

CLASS OF EQUIPMENT	TYPE OF EQUIPMENT (Van, Tank, Flat, etc.)	DATES		APPROXIMATE TOTAL MILES
CLASS OF EQUIPMENT	TYPE OF EQUIPMENT (Van, Tank, Flat, etc.)	FROM	TO	APPROXIMATE TOTAL MILES
Straight Truck
Tractor and Semi-Trailer
Twin Trailers
Other

	List states operated in during last five years
	List Special Courses or Training that will help you as a driver
	List safe driving awards held and who awards were presented by

ACCIDENT REVIEW FOR PAST 3 YEARS

	DATES	NATURE OF ACCIDENT (Head-On, Rear-End, Upset, etc.)	FATALITIES	INJURIES
Last Accident
Next Previous
Next Previous
Next Previous

If you need more space for accidents, give full details below.

TRAFFIC CONVICTION AND FORFEITURES FOR THE PAST 3 YEARS OTHER THAN PARKING VIOLATIONS

LOCATION	DATE	CHARGE	PENALTY

If you need more space for traffic convictions and forfeitures, give full details below.

NOTICE TO DRIVERS

Federal Motor Carrier Safety Regulations §40.25 (j) The employer must ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years.

Have you tested positive, or refused to test, on any pre-employment drug test or have you tested .02 or greater, or refused to test, on any pre-employment alcohol test during the past two years? YesNo

YOUR RIGHTS

Pursuant to 49CFR, § 391.23 (j), you have the following rights regarding investigative information

The right to review information provided by previous employers.
The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer.
The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

PRE-EMPLOYMENT URINALYSIS CONSENT

I understand that as required by the Federal Motor Carrier Safety Regulations, Title 49 Code of Federal Regulations, Section 382.103, all driver/applicants of this company must be tested for controlled substances as a pre-condition for employment.

I consent to the urine sample collection and testing for controlled substances.

I understand that a positive test result for controlled substances will render me unqualified to operate a commercial motor vehicle.

The medical review officer will maintain the results of my test. Negative and positive results will be reported to the company. If the results are positive, the controlled substance will be identified. The results will not be released to any other parties without my written authorization.

DOT REQUIRED SPLIT SAMPLE TESTING

As of August 15, 1994 Federal Regulations require all DOT drug tests to be collected in accordance with split sample procedures.

With this change the driver has the right to have the second bottle tested at a different NIDA approved lab should the initial test be confirmed positive. The driver will have 72 hours after a test is confirmed positive to request the second bottle be tested.

Should you request that the second bottle be testet; you will assume the cost of any subsequent testing. Should subsequent testing results report back as negative we will reimburse you for the cost of the testing.

Due to the additional expense of transporting the sample to another NIDA approved lab, and requirement that the confirmation be done by expensive Gas Chromatography, the testing of the second bottle will cost at least $225.00.

I've read the above notice and understand that I will be responsible for the cost of any subsequent testing charges.

I understand all of the above conditions and hereby agree to comply with them.

APPLICANT MUST READ AND SIGN

I certify that I have read and understand all of this employment 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 inquire of my personal, employment, financial or medical history and other 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 release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connections with my application. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an Investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I also understand that if offered a job, it may be conditioned on the results of a physical examination and drug test. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. I understand that false, misleading or omitted information from my application or interview(s) may result in my rejection as an applicant or discharge as an employee. I understand, also, that I am required to abide by all rules and regulations of the Company.
09/08/2010 Date*	Signature of Applicant* (Typing Name Signifies Signature)
	Send me a copy of application? Email Address*
ATTACHMENTS