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Class A CDL Truck Driver Job Application

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EDUCATION
 
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GENERAL
 
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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).
 
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DRIVER EXPERIENCE
 
* : The U.S. Department of Transportation requires that driver applicatnts state their date of birth §391.21 (b)(2).
   
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Driver Licenses held in past 3 years must be shown
State License # Type Expiration Date
 
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Class of Equipment Type of Equipment
(Van, Tank, Flat, etc.)
Dates Approximate
Total Miles
From To
Straight Truck
Tractor and Semi-Trailer
Twin Trailers
Other
 
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Dates Nature of Accident
(Head-On, Rear-End, Upset, etc.)
Fatalities Injuries
Last Accident
Next Previous
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Location Date Charge Penalty
 
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?
 
YOUR RIGHTS
Pursuant to 49CFR, §391.23 (j), you have the following rights regarding investigative information
  1. The right to review information provided by previous employers.
  2. 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.
  3. 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, §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.
 
IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with Shelba D Johnson ("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 Administration (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 electronic 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 Shelba D Johnson (“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.
 
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.
 
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  • Shelba D. Johnson Trucking, Inc.
  • 1640 Blair Street
  • Thomasville, NC 27360
  • Mailing Address
  • Shelba D. Johnson Trucking, Inc.
  • P.O. Box 7287
  • High Point, NC 27264
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