DRIVER EMPLOYMENT APPLICATION | Fastrak Express, Inc.

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, non-job-related disability, or any other protected group status.

Date

SS#

DOB

Position(s) Applied for

Name

First Name

Middle Name

Last Name

Address

Street

City

State

Zip Code

How Long?

Phone

ADDRESS FOR PAST THREE YEARS

Street

City

State

Zip Code

How Long?

Street

City

State

Zip Code

How Long?

Street

City

State

Zip Code

How Long?

Can you provide proof of age?YesNo

Do you have the legal right to work in the United States?YesNo

Have you worked for this company before?YesNo

From

Reason for leaving?

Are you now employed?YesNo

If not, how long since leaving last employment?

How did you hear about us?

Rate of pay expected

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.) Your present and previous employers will be contacted for the purpose of investigating your safety performance history as required by FMCSA. Please use additional paper if necessary.

Employer

Name:

Date

From:

To:

Address:

City:

State:

Zip:

Contact Person:

Phone#:

Position Held:

Salary/Wage:

Reason for leaving:

Were you subject to FMCSRs + while employed?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

Add an additional Employer

Employer

Name:

Date

From:

To:

Address:

City:

State:

Zip:

Contact Person:

Phone#:

Position Held:

Salary/Wage:

Reason for leaving:

Were you subject to FMCSRs + while employed?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

Remove Employer

Employer

Name:

Date

From:

To:

Address:

City:

State:

Zip:

Contact Person:

Phone#:

Position Held:

Salary/Wage:

Reason for leaving:

Were you subject to FMCSRs + while employed?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

Remove Employer

Employer

Name:

Date

From:

To:

Address:

City:

State:

Zip:

Contact Person:

Phone#:

Position Held:

Salary/Wage:

Reason for leaving:

Were you subject to FMCSRs + while employed?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

Remove Employer

Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Have you ever been convicted of a felony?YesNo

If yes, please explain fully on a separate sheet of paper and upload that here. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.

Military Status

Have you served in the U.S. Armed Forces?YesNo

Branch

Education

Experience and Qualifications- Driver

Driver’s Licenses

List all driver licenses or permits held in the past 3 years

State:

License No:

License Type:

Expiration Date:

State:

License No:

License Type:

Expiration Date:

State:

License No:

License Type:

Expiration Date:

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

Explanation:

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

Explanation:

IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS

Driving Experience

Class of Equipment

Straight Truck

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Add an additional Straight Truck

Class of Equipment

Tractor and Semi-Trailer

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Straight Truck

Class of Equipment

Tractor and Semi-Trailer

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Straight Truck

Class of Equipment

Tractor and Semi-Trailer

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Straight Truck

Class of Equipment

Tractor and Semi-Trailer

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Straight Truck

Class of Equipment

Tractor and Semi-Trailer

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Add an additional Tractor and Semi-Trailer

Class of Equipment

Tractor and Semi-Trailer

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Tractor and Semi-Trailer

Class of Equipment

Tractor and Semi-Trailer

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Tractor and Semi-Trailer

Class of Equipment

Tractor and Semi-Trailer

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Tractor and Semi-Trailer

Class of Equipment

Tractor and Semi-Trailer

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Tractor and Semi-Trailer

Class of Equipment

Tractor - Two Trailers

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Add an additional Tractor - Two Trailers

Class of Equipment

Tractor - Two Trailers

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Tractor - Two Trailers

Class of Equipment

Tractor - Two Trailers

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Tractor - Two Trailers

Class of Equipment

Tractor - Two Trailers

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Tractor - Two Trailers

Class of Equipment

Tractor - Two Trailers

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Tractor - Two Trailers

Class of Equipment

Other

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Add an additional Other Trailer

Class of Equipment

Other

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Other Trailer

Class of Equipment

Other

Type of Equipment (Van, Tank, Flat, Etc.):

From:

To:

Approx. No. of Miles (Total):

Remove Other Trailer

List States operated in the last five years :

Show Special Courses or Training that will help you as a Driver:

Which Safe Driving Awards do you hold and from whom?

ACCIDENT RECORD FOR THE PAST 3 YEARS OR MORE

Last Accident Date:

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

Fatalities:

Injuries:

Next previous Accident Date:

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

Fatalities:

Injuries:

Next previous Accident Date:

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

Fatalities:

Injuries:

Add more

Next previous Accident Date:

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

Fatalities:

Injuries:

Remove

Next previous Accident Date:

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

Fatalities:

Injuries:

Remove

Next previous Accident Date:

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

Fatalities:

Injuries:

Remove

Next previous Accident Date:

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

Fatalities:

Injuries:

Remove

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS

Location:

Date:

Charge:

Penalty:

Location:

Date:

Charge:

Penalty:

Location:

Date:

Charge:

Penalty:

OTHER THAN PARKING VIOLATIONSYesNo

Driver's License Upload

Please upload a copy of your driver's license here:

Front:

Back:

EXPERIENCE AND QUALIFICATIONS

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):

Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the attached job description)?

If yes, explain if you wish:

TO BE READ AND SIGNED 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.

As part of the application process, I am aware that certain prequalification procedures are involved. This may include a driving test, training and other pre hiring examinations. I understand and agree that during this period I am not an employee of the company, and I am not entitled to receive any pay or compensation for my time spent in these procedures.

I authorize you to make such investigations and inquiries of my personal, employment, financial and/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 Fastrak Express, Inc

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 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.

Applicant’s Signature

Date