Driver's Application for Employment

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status or non-job related disability or any other protected group status.

Date of Application                 Home Phone Number

Name: (Last, First, Middle):

Social Security No: 

List All Your Addresses for the Past 3 Years:

Current Address:(Street/Mailing)

                   City/State,Zip Code)

                   Phone    How Long? 

List All Previous Address in the Past 3 Years

Do you have the legal right to work in the United States? Yes No

Date of Birth: January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year

Can you provide proof of age? Yes No

Have you worked for this company before? Yes No   Where?

DATES: From:   To:    Position

Reason for Leaving: 

Are you now employed? Yes No   If not, how long since leaving last employment?

Who Referred You?

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide complete information on all employers during the last 3 Years.  Provide additional 7 years employment history driving any commercial motor vehicle in commerce.  All previous employers of the past three years from date of this application will be contacted, for the purpose of investigating your safety performance history concerning general driver identification, employment verification, accident data elements required by FMCSRs section 390-15(b)(1), and any violations of 49 CFR Parts 40 and 382 concerning drug and alcohol.

If there is not enough room in the employer section, please go to the bottom of this form and use the additional information box.

EMPLOYER - 1

Name: From: January February March April May June July August September October November December , To: January February March April May June July August September October November December ,

Address:   Position: 

CityStateZip      Wage: 

Contact Person:

Phone Number:     Reason for Leaving:

1.  Were you subject to the Federal Motor Carrier Safety Regulations while employed there?  Yes No

2.  Did you perform a safety sensitive function in Any DOT regulated mode subject to alcohol and

     drug testing as required by 49 CFR Part 40?                                                                                  Yes No

EMPLOYER - 2

Name: From: January February March April May June July August September October November December , To: January February March April May June July August September October November December ,

Address:   Position: 

CityStateZip      Wage: 

Contact Person:

Phone Number:     Reason for Leaving:

1.  Were you subject to the Federal Motor Carrier Safety Regulations while employed there?  Yes No

2.  Did you perform a safety sensitive function in Any DOT regulated mode subject to alcohol and

     drug testing as required by 49 CFR Part 40?                                                                                  Yes No

EMPLOYER - 3

Name: From: January February March April May June July August September October November December , To: January February March April May June July August September October November December ,

Address:   Position: 

CityStateZip      Wage: 

Contact Person:

Phone Number:     Reason for Leaving:

1.  Were you subject to the Federal Motor Carrier Safety Regulations while employed there?  Yes No

2.  Did you perform a safety sensitive function in Any DOT regulated mode subject to alcohol and

     drug testing as required by 49 CFR Part 40?                                                                                  Yes No

EMPLOYER - 4

Name: From: January February March April May June July August September October November December , To: January February March April May June July August September October November December ,

Address:   Position: 

CityStateZip      Wage: 

Contact Person:

Phone Number:     Reason for Leaving:

1.  Were you subject to the Federal Motor Carrier Safety Regulations while employed there?  Yes No

2.  Did you perform a safety sensitive function in Any DOT regulated mode subject to alcohol and

     drug testing as required by 49 CFR Part 40?                                                                                  Yes No

ACCIDENT RECORD

(Must Comprise the Last 3 Years)

                                Dates                    Location                    # of Injuries        # of Fatalities    Hazmat Spill

Last Accident                                               Yes No        

Next Previous                                               Yes No      

Next Previous                                               Yes No      

TRAFFIC CONVICTIONS and FORFEITURES

(Must Comprise the Last 3 Years)

Location                                       Date                                Charge                                Penalty

EXPERIENCE and QUALIFICATIONS - DRIVER

Driver Licenses: State:       License No: 

                        Type:  CDL-A CDL-B CDL-C Non CDL                Expiration Date: 

A.  Have you ever been denied a license, permit or privilege to operate a motor vehicle?  Yes No

B.  Has any license, permit or privilege ever been suspended or revoked?  Yes No

IF YOUR ANSWER TO EITHER A or B IS "YES", PLEASE GIVE ADDITIONAL INFORMATION IN THE BOX BELOW

Additional Explanation (please complete here) 

EDUCATION

Highest Grade Completed:

Last School Attended (Name, City): 

DRIVING EXPERIENCE

Please indicate class of equipment, type of equipment, dates driven, and approximate number of miles.

List states operated in for last 5 years: 

List special courses or training that will help you as a driver:  (below)

Show any trucking, transportation or other experience that may help in your work for this company

List courses and training other than shown elsewhere in this application

List special equipment or technical materials you can work with (other than those already shown):

Additional Information Section - please use if you have addition employers to list, be sure to include company name, address, telephone number and contact name

The 49 CRF 40.25 requires the following information be asked of individuals seeking to begin safety-sensitive duties for the first time, including any employee transferring into safety-sensitive functions as defined in 49 CFR 382.107.

You must answer the following questions regarding drug and alcohol testing to which you applied for, but did not obtain, safety-sensitive transportation work covered by a DOT agency drug and alcohol testing rules during the past three years.

Respond to the following questions

1.    Did you ever test positive on any pre-employment drug test in the past three years?          Yes No

2.    Did you ever test <0.02 on any pre-employment alcohol test in the past three years?        Yes No

3.    Did you ever refuse a pre-employment drug or alcohol test in the past three years?           Yes No

4.    Can you travel in and through Canada?                                                                            Yes No

TO BE READ AND ACKNOWLEDGED BY APPLICANT

This certifies that this application was completed by me, 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 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.

In the event of employment, I understand that false or misleading information given in my application or interview may result in discharge.  I understand, also, that I am required to abide by all rules and regulations of the company.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CRF 391.23(d) and (e).  I understand that I have the right to:

          Review information provided by previous employers;

Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer or;

Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

I acknowledge that I have read and understand the above statement and by putting an X in the pink box, I give permission to Karl R. Johnson Trucking, Inc. to proceed with processing my application.  

After you complete the permission box, click the submit button below.