Driver Application - Nicho Produce

Step 1 of 3

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Your Personal Information

Company

Street Address

City, State, and Zip Code

Your Name

First Middle Last

Address

Street Address Address Line 2 City State ZIP Code

Date of Birth

Social Security No.

Hire Date

Email Address

Phone

Previous Three Years Residency

Street

City

State & Zip Code

# Years

License Information

Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.

State

License No.

Type

Expiration Date

Driving Experience

Class of Equipment

Type of Equipment

(Van, Tank, Flat, Etc.)

Dates

Start – End

Approx. No. of Miles (Total)

Accident Record for Past 3 Years or More

Dates

Nature of Accident (Head-On, Rear-End, Upset, Etc.)

Number Fatalities

Number Injuries

Chemical Spills (Yes/No)

Traffic Convictions and Forfeitures for the Past 3 Years (Other than Parking Violations)

Date Convicted (Month/Year)

Violation

State of Violation Location

Penalty (Forfeited Bond, Collateral, and/or Points)

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

Yes

If yes, explain:

Has any license, permit, or privilege ever been suspended or revoked?

Yes

If yes, explain:

Employment Record

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).

Last Employer: Name

Address

Must list the complete mailing address: street number and name, city, state, and zip code.

Phone

Position Held

From

Salary

Reasons for Leaving

Any gaps in employment and/or unemployment must be explained. Include dates (month/year).

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Yes

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes

Second Last Employer: Name

Address

Must list the complete mailing address: street number and name, city, state, and zip code.

Phone

Position Held

From

Salary

Reasons for Leaving

Any gaps in employment and/or unemployment must be explained. Include dates (month/year).

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Yes

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes

Third Last Employer: Name

Address

Must list the complete mailing address: street number and name, city, state, and zip code.

Phone

Position Held

From

Salary

Reasons for Leaving

Any gaps in employment and/or unemployment must be explained. Include dates (month/year).

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Yes

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make sure investigations and inquiries to 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(s) 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 CFR 391.23(d) and (e). I understand that I have the right to:

Review information provided by current/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; and
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.”

Date

Applicant's Signature

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.

Date

Applicant's Signature

Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

Are you currently employed?

Yes

Any felony conviction?

Yes

If so, when?

Education History

Name & Location of School

High School

Did you graduate?

Yes

College

Did you graduate?

Yes

Trade School

Did you graduate?

Yes

General Information

In what year did you receive your CDL license?

Class A or B?

This position requires heavy lifting and manual labor. Do you have any physical disabilities (injuries or surgeries) that would prevent you from lifting heavy weight up to 100 lbs?

Yes

IT IS REQUIRED BY STATE LAW THAT ALL CDL DRIVERS PASS A DRUG TEST.

If HIRED, and fail the test, I agree to pay the cost of test, $50.

(Initials)

If HIRED, and stop working before the end of THREE months, I agree to pay the cost of test, $50.

(Initials)

Authorization

“I certify that the facts contained in this application are true an complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability related or medical information in manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws. I have read and understand this entire document and confirm so by signature.”

Date

Signature