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Contact & Personal Information
I am applying for one of the following driving positions:


Truck Driving Experience:*
Years

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Social Security:*
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Date of Birth:*
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First Name:*
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Middle Initial:*
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Last Name:*
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Address:*
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City:*
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State:*
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Zip:*
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Telephone:*
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Cell Phone:*
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Email Address:*
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Have you ever been known by any other name?:


If employed, can you provide verification of your legal right to work in the United States?:

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Can you legally travel between the U.S. and Canada?:

If No, please explain:
Who referred you to our Company?:
How did you hear about us?:
Personal Information
The conviction of a crime is not an automatic bar to employment. All circumstances will be considered including the nature of the offense and the relationship of the offense to this Company's business. Failure to disclose all convictions will result in immediate disqualification.

Answer the following Yes or No.
If Yes, provide dates and explain in details column Date(s) / Details
Have you ever been convicted of a felony, received a deferred prosecution, or have any felony charges currently pending?:

Conviction Date:
/ /
Conviction Details:
Have you ever been convicted of a misdemeanor, received a deferred prosecution, or have any misdemeanors currently pending?:

Conviction Date:
/ /
Conviction Details:
Have you ever been convicted of operating a motor vehicle while under the influence of alcohol or a controlled substance, or are any charges pending, including reduction to a lesser charge? (List all dates):

Conviction Date:
/ /
Conviction Details:
Have you ever been convicted of possession, sale, transfer or use of alcohol or a narcotic drug, amphetamine, inhalant, or derivative thereof, or have a current charge pending? (List all dates):

Conviction Date:
/ /
Conviction Details:
Have you ever tested positive for drugs/controlled substance or alcohol, or refused to submit to a required drug/alcohol test?:

Conviction Date:
/ /
Conviction Details:
Have you ever been denied a license, permit or privilege to operate a motor vehicle?:

Conviction Date:
/ /
Conviction Details:
Has any driver's license, permit or privilege ever been suspended or revoked?:

Conviction Date:
/ /
Conviction Details:
Have you ever had a citation for leaving the scene of an accident?:

Conviction Date:
/ /
Conviction Details:
Personal Information
List Additional Addresses in Last 3 Years:
Street City State Time Period
From:
/ /
To:
/ /
From:
/ /
To:
/ /

Licenses: (List all driver license numbers assigned to you in the past 10 years.)
State License Number Personal Commerical Hazmat Yes? Hazmat No? Expires
/ /
/ /
/ /

Moving Violations: List all tickets and forfeitures for the past 5 years. Be sure to list all careless or reckless driving convictions or pending reckless or careless driving citations as such. (IF NONE, WRITE NONE)
Date Accident Type City/State Preventable/Non-Preventable #Fatalities # Injuries

If ever involved in a fatality accident, please explain:
Education & driving school
Education:
Circle highest grade completed:







High School:



College:



CDL Driving School Name:
City :
State :
Phone :
Fax :
Email :
Course Length (Weeks):
CDL Graduation Date:
/ /
Employment History
Employment History: Starting with your most recent employer, provide 10 years of work history for driving jobs, 5 years of work history for non-driving jobs. Please include all phone numbers. Account for all time, including military service, periods of self-employment, and unemployment for more than 2 weeks. Provide documentation for periods of self-employment and military that includes affidavits, tax records, or DD214 long form for the last 5 years.
Have you ever worked for this Company before?:

If yes, when:
Position:
Period of Non-Employment:
From:
/ /
To:
/ /
This field is required. Please enter a value.
Reason:
Current or Last Employer:
Employed From:*
/ /
This field is required.
To:*
/ /
This field is required.

Miles Driven Weekly:*
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Company Name:*
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Phone:*
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Address:*
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City:*
This field is required.
State:*
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Position Held:*
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Truck Type:*
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Pay Rate:*
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Were you subject to the FMCSR's:

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol testing requirements of 49 CFR Part 40?

Reason for leaving: *
This field is required.
May we contact this employer?

Employment History
Period of Non-Employment:
From:
/ /
To:
/ /
Reason:
Prior Employer:
Employed From:
/ /
To:
/ /

Miles Driven Weekly:
Company Name:
Phone:
Address:
City:
State:
Position Held:
Truck Type:
Pay Rate:
Were you subject to the FMCSR's:

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol testing requirements of 49 CFR Part 40?

Reason for leaving
May we contact this employer?

Period of Non-Employment:
From:
/ /
To:
/ /
Reason:
Prior Employer:
Employed From:
/ /
To:
/ /

Miles Driven Weekly:
Company Name:
Phone:
Address:
City:
State:
Position Held:
Truck Type:
Pay Rate:
Were you subject to the FMCSR's:

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol testing requirements of 49 CFR Part 40?

Reason for leaving
May we contact this employer?

Period of Non-Employment:
From:
/ /
To:
/ /
Reason:
Prior Employer:
Employed From:
/ /
To:
/ /

Miles Driven Weekly:
Company Name:
Phone:
Address:
City:
State:
Position Held:
Truck Type:
Pay Rate:
Were you subject to the FMCSR's:

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol testing requirements of 49 CFR Part 40?

Reason for leaving
May we contact this employer?

Period of Non-Employment:
From:
/ /
To:
/ /
Reason:
Prior Employer:
Employed From:
/ /
To:
/ /

Miles Driven Weekly:
Company Name:
Phone:
Address:
City:
State:
Position Held:
Truck Type:
Pay Rate:
Were you subject to the FMCSR's:

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol testing requirements of 49 CFR Part 40?

Reason for leaving
May we contact this employer?

Period of Non-Employment:
From:
/ /
To:
/ /
Reason:
Prior Employer:
Employed From:
/ /
To:
/ /

Miles Driven Weekly:
Company Name:
Phone:
Address:
City:
State:
Position Held:
Truck Type:
Pay Rate:
Were you subject to the FMCSR's:

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol testing requirements of 49 CFR Part 40?

Reason for leaving
May we contact this employer?

APPLICANT AGREEMENT

APPLICANT AGREEMENT


To be carefully read and signed by applicant. If you have any questions or require an explanation of the terms of this Agreement, please ask for clarification.

I hereby authorize any law enforcement agency, court of record, or any third party agency to furnish Logistic One Ltd. of Warren MI (the "Carrier") with information concerning my Motor Vehicle Record, or any felony or misdemeanor of which I have been convicted.

I understand and agree that the Carrier may procure my past employment records and background/credit information from a consumer credit bureau, as the Carrier deems necessary for the consideration of my employment.

I understand that this application for employment will not be accepted as final until satisfactorily completing a medical examination including drug testing, as well as a driving skill exam and personal interview. The location of these exams and requirements shall be at the sole discretion of the Carrier. I further agree to provide access to previous medical records if required.

I understand my application may be transferred to an electronic filing system, and the original may not be retained.

I acknowledge and agree that, as a condition of employment with the Carrier, I will be subject to the alcohol and controlled substances regulations as published in the Federal Motor Carrier Safety Regulations (FMCSR), parts 40 and 382. I further agree to submit urine and breath samples as necessary to comply with the testing requirements of the regulations. I understand that a positive test result for controlled substances (including adulterated samples or refusals to test) or test results indicating a Blood Alcohol Content (BAC) of .04 or greater will be grounds for refusal to hire or immediate termination of my employment, if hired.

I understand that at any point in the future, whether I am actively employed by the Carrier or not, the Carrier may provide information concerning my employment and services with the Carrier to any party that requests such information. I agree that said information may be furnished on my behalf without any liability or damages to the Carrier.

I understand and agree that my submitting this application to the Carrier for employment in no way obligates the Carrier to offer me employment.

I understand that if I am hired, my employment will be "at will", meaning for no definite period, regardless of the period of payment of my wages. I further understand that I have the right to terminate my employment at any time with or without notice, and the Carrier has the same right. I understand that no supervisor, manager, or executive of the Carrier, other than the President, has the authority to alter the foregoing and the President may do so only in writing that is signed by both the President and the employee in question.

I hereby authorize, without liability, any person or organization whose name I have given as reference, or by whom I have been previously employed or contracted with, to furnish Logistic One Ltd. of Warren MI any information they may have concerning my character, habits, ability, financial responsibility, job performance, reasons for leaving employment/lease, and all information concerning my employment/lease. I hereby release all such persons and organizations from any claims for damages of any kind, which may occur to me by reasons of furnishing such information.

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. Any false, misleading or incomplete statement of the information requested in this application and any supplemental material submitted shall be sufficient grounds for disqualification of this application or termination from employment, if this application results in employment.

I have read and understand the terms of the above Agreement.

Applicant's Printed Name:*
(Check this box to confirm your digital signature)*
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PAST EMPLOYMENT INFORMATION REQUEST FORM AUTHORIZATION*
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DRUG/ALCOHOL TESTING HISTORY INQUIRY AUTHORIZATION*
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IMPORTANT NOTICE REGARGING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE AUTHORIZATION*
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