Form P.O. Box 403/382 Route 15 South Wharton, New Jersey 07885 Phone: 973-328-0050/Fax: 973-328-8410 APPLICATION FOR TRACTOR-TRAILER OPERATOR (Pursuant to 49 CFR 391 al et) In compliance with Federal and State Equal Employment Opportunity Laws, Qualified applicants are considered for all positions without regard to race, color, eligion, sex, age, natural origin, ethnic identity, or marital status. ALL FIELDS MARKED WITH * ARE REQUIRED IN ORDER TO PROCESS YOUR APPLICATION *PERSONAL INFORMATION *IN CASE OF AN EMERGENCY NOTIFY ARE YOU A U.S. CITIZEN? * YesNo IF NO, DO YOU HAVE A PERMANENT RESIDENT ALIEN CARE? * YesNo HAVE YOU WORKED FOR OUR COMPANY BEFORE? * YesNo HOW DID YOU LEARN ABOUT US? NEWSPAPERBILLBOARDRADIO * DRIVER LICENSE INFORMATION ENDORSEMENTS XYesNo TYesNo HYesNo NYesNo PYesNo *MOTOR VEHICLE RECORD QUALIFICATIONS List all drivers’ license held in the past 5 years STATE LICENSE NUMBER CDL CLASS ENDORSEMENTS EXP. DATE *ACCIDENT RECORD (If none, please write none) List all accident involvement with any motor vehicle for the past 5 years (even if not at fault): DATE NATURE OF ACCIDENT (Heard-On, Rear-end, ETC.) Chargeable CMV/Car Fatalities Injuries Last Accident Previous Accident Previous Accident Previous Accident Even if you do not remember dates you must still write down any accidents. If you have had none write NONE in the space provided. NOTE: LIST ALL accidents, regardless of vehicle type. Failure to list an accident may result in your disqualification. *TRAFFIC CONVICTIONS (If none, please write none) List all convictions and forfeitures for the past 5 years (any motor vehicles, other than parking violations): DATE LOCATION (City, State) VIOLATION(speeding, disobeying traffic device, etc. PENALTY TRAFFIC CONVICTION IN CMV YES NO HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE? * YESNO (if yes, give dates & explain in detail reason and final outcome of suspension or revocation) HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED? * YESNO (if yes, give dates & explain in detail reason and final outcome of suspension or revocation) *DRIVING EXPERIENCE Class of Equipment Type of Trailer Dates States of Operation the last three years From To Straight Truck Tractor & Semi Trailer Tractor & 2 Trailers Other Have you been awarded any safe driving awards and from whom? *GENERAL INFORMATION Do you have TWIC card? YESNO Do you have a Passport? YESNO EDUCATION AND TRAINING * G.E.D. (Graduate Equivalency Diploma) YESNO List any training program presently attending or completed (Truck driving schools, trade schools, ETC.) DID YOU GRADUATE YESNO MILITARY SERVICE RECORD * HAVE YOU EVER SERVED IN THE U.S. ARMED FORCES? * YESNO DATES OF SERVICE * TO PERSONAL HISTORY FOR THE PAST 10 YEARS* (DO NOT LEAVE GAPS BETWEEN DATES. MUST LIST PHONE NUMBER OF PAST COMPANIES) PRESENT OR MOST RECENT POSITION Dates: From Month/Year Position Held Company Average Weekly Earning Address Hourly or Mileage Rate Paid City State Zip Type of Trailer Pulled Reason for leaving Telephone Type of Equipment Driven Supervisor Number of incidents/accidents Full or Part Time Hours or Miles/week States/Regions you drove in Were you subject to the FMCSRs** YesNo Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo PERIOD OF UNEMPLOYMENT (IF ANY) DATES: FROM MONTH/YEAR TO RECENT POSITION Dates: From Month/Year Position Held Company Average Weekly Earning Address Hourly or Mileage Rate Paid City State Zip Type of Trailer Pulled Reason for leaving Telephone Type of Equipment Driven Supervisor Number of incidents/accidents Full or Part Time Hours or Miles/week States/Regions you drove in Were you subject to the FMCSRs** YesNo Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo PERIOD OF UNEMPLOYMENT (IF ANY) DATES: FROM MONTH/YEAR TO RECENT POSITION Dates: From Month/Year Position Held Company Average Weekly Earning Address Hourly or Mileage Rate Paid City State Zip Type of Trailer Pulled Reason for leaving Telephone Type of Equipment Driven Supervisor Number of incidents/accidents Full or Part Time Hours or Miles/week States/Regions you drove in Were you subject to the FMCSRs** YesNo Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo PERIOD OF UNEMPLOYMENT (IF ANY) DATES: FROM MONTH/YEAR TO MANDATORY USE FOR ALL MONTHLY ACCOUNT HOLDERS IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service 1.In connection with your application for employment with (“Prospective Employer”) it may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration(FMCSA). If the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make anyother adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report uponwhich its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any finaladverse action. If any final adverse action is taken against you based upon your driving history or safety report, the ProspectiveEmployer will notify you that the action has been taken and that the action was based in part or in whole on this report. TheProspective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that theProspective Employer may obtain such background reports, please read the following and sign below: 2. I authorize 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 consenting to the release of safety performance information including crash data from the previous five (5) years andinspection 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. 3.I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safetyinformation 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 am challenging crash or inspection information reportedby a State, FMCSA cannot change or correct this date. I understand my request will be forwarded by the DataQs system to theappropriate State for adjudication. 4.Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report doesnot 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 FMCSR violations that have been adjudicated by a court of law will also appear and remain, on a PSP report. I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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 NICT on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain a driver’s written or electronic consent prior to accessing the driver’s PSP report. Further, account holders are required by FMCSA to use the language provided in paragraphs 1-4 of this document to obtain a prospective driver’s consent. The language must be used in whole, exactly as provided. The language may be included with other consent forms or language at the discretion of the account holder, provided the four paragraphs remain intact and the language is unchanged. Company Name: CARBON EXPRESS, INC. FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving may be obtained on you for employment purposes. These reports are required by Sections 282.413, 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. Applicant’s signature P.O. Box 403/382 Rout 15 South Wharton, New Jersey 07885 Phone: (973) 328-0050/Fax: 973-328-8410 INQUIRY TO PAST EMPLOYER Applicant: Complete Top Section Only Applicant’s Name: (print clearly) Social Security No You are hereby authorized to give to Carbon Express, Inc., all information regarding my services; character and conduct while in your employ, and you are released from liability that may result from giving such information. In order to enable Carbon Express, Inc. to comply with the requirements of 49 CFR, 40.311, 382.413, I hereby consent to Carbon Express, Inc. obtaining from my prior employers the information pertaining to me which they are required to maintain by 49 CFR 382.401(b)(1)(i) through (iii) regarding alcohol tests with a concentration result of 0.04 or greater, positive controlled substance test results and refusal to be tested with the two (2) years preceding the date of this application. I hereby authorize and direct my prior employers to release such information to Carbon Express, Inc. in personal interviews, telephone interviews, letter, or any other method that insures confidentiality. I hereby authorize Carbon Express, Inc. to release such information to any of its personnel whose duties require them to access this application or to make any recommendations or decisions with respect to it. I acknowledge, that I have the right to due process as identified in 49 CFR 391.23 to correct information submitted under this authorization. Applicant’s Signature Date *APPLICANT STOP HERE * Former Employer: Please provide the following information about this applicant. Company Driver Owner Operator Driver for O/O Equipment: Tractor & Trailer-Vans Tractor & Trailer-Tank Flatbed Other Accidents Is applicant eligible for rehire? If no, why? In accordance with part 382.405 (f) and 382.413 (a) (b) (c) (d) (e) (f): Has this person ever had an alcohol test concentration of 0.04 or greater in the past two years? YesNo Has this person ever tested positive for a controlled substance in the past two years? YesNo Has this person ever refused a required test for drugs or alcohol in the past two years? YesNo Has this person violated other DOT drug or alcohol regulations in the past two years? YesNo Have you received information from a previous employer that this person violated drug or alcohol regulations in the past two years? YesNo 1st Attempt 2nd Attempt 3rd Attempt 4th Attempt 5th Attempt Under 49 CFF 391.23, failure to provide the above information should be reported to US DOT (FMCSA) following procedure specified in 49 CFR 386.1. CONFIDENTIAL REPORT OF PERSONAL REFERENCE Please indicate your opinion by placing a check (√) in the appropriate column. CHARACTERISTICS EXCELLENT GOOD FAIR POOR Disposition, Tact, Ability to get along with others Initiative, Resourcefulness Safety Habits Driving Skills Attitude Loyalty FOR PROSPECTIVE EMPLOYER’S RECORDS MAINTAIN THIS INFORMATION IN THE DRIVER QUALIFICATION FILE FOR 3 YEARS AFTER THE PERSON’S EMPLOYMENT BY THE MOTOR CARRIER CEASES. Or print out completed form and fax to: 973-328-8410
