DOT Application for Employment

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Attach Resume:
*Email:
Applying for:

How did you learn about us? Advertisement    Friend     Walk-in     Relative     Other
If other:

Applicant Information

*First Name: *Last Name:
MI: Social Security:
*Phone:
*Address:
Apartment/Unit # *City
*State *Zip
If your above address is less than three (3) years. continue them below to cover the previous three (3) year period.
1. Address
Dates: ------ To ------
*City *State
*Zip
2. Address
Dates: ------ To ------
*City *State
*Zip
3. Address
Dates: ------ To ------
*City *State
*Zip
Are you over 18 years of age? Yes    No If you are under 18 years of age, can you provide proof of eligibility to work? Yes    No
Are you 21 years of age (for interstate or hazardous materials)? Yes    No
*Have you ever filed an application with us before?:  Yes     No
*Have you ever worked for this company?:  Yes     No
If so, when?: ------ To ------
Are you able to perform the duties of the job for which you are applying? Yes    No
If no, please describe:
*Are you currently employed?:  Yes     No
*May we contact your present employer?:  Yes     No
*Are you legally authorized to work in the United States?: Proof of identity and work authorization will be required upon employment.  Yes     No
Date Available:

Availability:  Full-Time    Part-Time    Shift Work    Temporary
Can you travel if a job requires it?  Yes     No
*Have you ever been convicted or pled guilty or no contest to a felony offense?
 Yes     No
If yes, please explain:
For purposes of employment with LATX Operations, "convictions" include, but are not limited to, sentenced to confinement, paid fine, time served, placed on probation (including deferred adjudication), and court-ordered restitution.
City/State
Charge
*Please explain:

I, agree to immediately notify LATX Operations if I am convicted of, receive deferred adjudication in, or otherwise plead guilty or no contest to a felony or any crime involving dishonesty or a breach of trust while my application is pending or during my period of employment, if hired.

Please list the names of any relatives or friends employed by LATX Operations

Education

High School:   Address:
Graduate:    Yes     No   Degree:
College:   Address:
Graduate:    Yes     No   Degree:
Other:   Address:
Graduate:    Yes     No   Degree:
Current Certifications/Licenses Held:

Emergency Contact

Person to Contact in Case of an Emergency

This information is to facilitate contact in the event of an emergency and is not used in the selection process.

Full Name Phone
Address
Their Place of Employment Phone
Address
Their Relationship to You

Employment History

Start with your present or last job. You may also include any activities which you believe demonstrate your qualifications for the position applied. If applicant is too young to have an employment history going back ten (10) years, include schools attended or whatever applicant was doing.

Company Name: Complete Address
(w/ City, State, Zip):
Phone: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
Start Date:
(mm/dd/yyyy)
  End Date:
(mm/dd/yyyy)
 
Reason for Leaving: May we contact your previous employer for a reference?  Yes    No
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?  Yes    No
Were you subject Federal Motor Carriers Safety Regulations (FMCSR)?  Yes    No
Add Employer

Accident Record and Traffic Convictions

Include vehicles having a GVWR of 26,001 lbs. or more (or 10,000 lb. for interstate), vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

Accident Record for past 3 years or more. If none, write "none".

Dates Type of Vehicle Nature of Accident (Head-On, Rear-End, Upset, Etc.) Fatalities Injuries

List all violations of motor vehicle laws or ordinances (other than parking violations) of which you were convicted, forfeited bond, or collateral during the past three (3) years.

Location Date Charge Penalty

Experience and Qualifications - Driver

Driver's Licenses
State License No. Type Expiration Date

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?  Yes    No
Has any license, permit, or privilege ever been suspended or revoked?  Yes    No
Include a detailed explanation of the facts and circumstances for each denial, revocation, or suspension.

Driving Experience (If None, Write "None")

Class of Equipment Type of Equipment (Van, Tank, Flat, Etc.) Date From Date To Approx No. of Miles (Total)
Straight Truck
Tractor & Semi-Trailer
Tractor - Two Trailers
Motor coach - School Bus
Other
List states operated in for 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?

Experience and Qualifications - Other

Show any trucking, transportation, or other experience that may help in your work for this Company.
List courses and training other than those shown elsewhere in this application.
List special equipment or technical materials you can work with (other than those already shown).

DRUG TESTING 49 CFR 40.2S(j)

Have you ever tested positive or refused to test on any pre-employment drug or alcohol test administered by an employer to which you have applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?  Yes    No
If YES --- Have you successfully completed the return to duty process?  Yes    No
If YES --- Documentation MUST BE PROVIDED before any safety-sensitive transportation function is performed.  Yes    No
If yes, please give details.

Applicant's Statement

Notification and Agreement

YOUR RIGHTS REGARDING SAFETY PERFORMANCE HISTORY INFORMATION

The information you provided on this application may be used, and the applicant's prior employers may be contacted, for the purpose of investigating the applicant's safety performance history information. Pursuant to Federal Motor Carrier Safety Regulations 49 CFR Sec. 391.23 (i)(1), you have the following rights with regard to the safety performance history information provided by your previous employers.

THE RIGHT TO RMEW SAFETY PERFORMANCE RECORDS

You have the right to review the records provided by your previous employers. You must make your request to review in writing and submit it to your prospective employer no later than thirty (30) days after employment begins or notification of employment is made. You will be provided with the records within five (5) business days of receipt of your written request. If the prospective employer has not rec~ived the records at the time of your request, then the five (5) day period to provide access will begin on the day the records are received from the previous employer. If you fail to arrange to pick up or receive the requested records within thirty (30) days of when they are first made available to you, then your right to review is considered waived.

THE RIGHT TO HAVE ERRONEOUS INFORMATION CORRECTED

If you believethere is an error in the records, you have the right to have your previous employer correct the error. Send your request for correction to the previous employer that provided the records in question. The previous employer must either correct and forward the record to the prospective employer or notify you within fifteen (15) days of receiving your request that they do not agree the record is in error. If the previous employer corrects and forwards the record as re51uested, that employer must also retain the corrected information as part of your safety performances history record and provide it to subsequent prospective employers when requests for this information are received.

THE RIGHT TO REBUT DISPUTED INFORMATION

If the previous employer does not agree that information in the records provided is in error, you may rebut the disputed information in writing and send it to the previous employer with instructions to include the rebuttal in your safety performance history file. Within five (5) business days of receiving your rebuttal, the previous employer must; forward a copy of the rebuttal to the prospective employer; append the rebuttal to your safety performance information and include it as part of the response for any subsequent investigating prospective employers for the duration of the three (3) year data retention requirement period. You may submit a rebuttal initially without a request for correction, or subsequent to a request for correction.

THE RIGHT TO REPORT FAILURES TO CORRECT ERRONEOUS INFORMATION

You may report failures of a previous employer to correct information or include your rebuttal as part of the safety performance, to the Federal Motor Carrier Safety Administration by following procedures specified at 49 CFR Section 385.12.

CERTIFICATION

"I certify 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"

DISCLOSURE TO CONSUMER

As part of our employment process, we may obtain where permitted, one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as:

iiX, a Verisk Analytics Business
1716 Briarcrest Drive
Suite 200
Bryan, Texas 77802

  • Consumer reports may include background, employment history, academic and/or professional credentials, military service, credit history, and driving history. The information gathered also may involve a criminal history and/or alcohol or drug use history, if any.

  • An investigative consumer report may include information about your character, general reputation, personal characteristics and mode of living that may be obtained by interviews with individuals who may have knowledge concerning any such items of information. This also may include contacts of all listed prior employers to verify your employment history.

  • If your employment falls under the federal Department of Transportation ("DOT") and the Federal Motor Carrier Safety Administration ("FMCSA"), including 49 CFR § 391.23, the report could include your driving, safety inspection and performance history from the FMCSA.

Under the provisions of the Fair Credit Reporting Act ("FCRA"), 15 U.S.C. § 1681 et seq.; FMCSA regulations in the Federal Code of Regulations, including 49 CFR § 40;329; and certain state laws, before we can seek such reports, where permitted, we must have your written permission to obtain the information.

You have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation. You also are entitled to a copy of that document entitled "Rights Under the Fair Credit Reporting Act". Under the FCRA, before we take adverse action on the basis, in whole or in part, of information in a consumer report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

  • Notice to California Applicants: Under California law, the reports ordered about you for employment purposes within the State of California are defined as "investigative consumer reports." These reports may contain information on your character, general reputation, personal characteristics and mode of living. Under California Civil Code § 1786.22, you may view the report(s) maintained at iiX during normal business hours. You also may obtain a copy by submitting proper identification and paying the cost of duplication by appearing at iiX in person, by mail, or by telephone. iiX is required to have personnel available to explain the report(s) and to explain any coded information. If you appear in person, you may be accompanied by a person of your choice, if s/he furnishes proper identification.

  • Notice to Massachusetts Applicants: Under Massachusetts law, an employer is prohibited from making written, pre-employment inquiries of an applicant about his or her criminal history. MASSACHUSETTS APPLICANTS SHOULD NOT RESPOND TO ANY OF THE QUESTIONS SEEKING CRIMINAL RECORD INFORMATION.

AUTHORIZATION TO OBTAIN INFORMATION

I have read and understood the preceding Disclosure to Consumer. Under the Fair Credit Reporting Act ("FCRA"), 15 U.S.C. § 1681 et seq., the regulations applicable to the federal Department of Transportation's Federal Motor Carriers Safety Administration, including 49 CFR § 40.329, tile Americans with Disabilities Act and all other applicable federal, state, and local laws, I hereby authorize and permit the above named company to obtain information about me, where permitted, which may pertain to my employment records, driving history records, driving performance and safety history, criminal history, credit history, civil records, workers' compensation (post-offer only), alcohol and drug testing, verification of my academic and/or professional credentials, and information and/or copies of documents from any military service records.

I understand an "investigative consumer report" may include information as to my character, general reputation, personal characteristics, and mode of living that may be obtained by interviews with individuals who may have knowledge concerning any such items information. I authorize information to be obtained from my former employers to satisfy driver qualification regulations.

DOT Drivers. I understand that Title 49 of the Federal Code of Regulations, § 391.23, requires that my prospective employer and/or its agent(s) may contact employers of a driver within the last three years under the regulation of the Department of Transportation. Information such as dates of employment, position, accident history, as well as information pertaining to my drug and alcohol testing history, may be requested from each employer in accordance with Sections 391.23 and 49 CFR 40.25.

By signing below, I consent to and authorize the gathering of this information by my prospective employer or employer and those who my prospective employer has engaged to request and obtain this information including former employers, and/or from or through a consumer reporting agency, such as iiX, a Verisk Analytics Business.

I understand and acknowledge that the information provided in the consumer reports or investigative consumer reports may assist my employer or prospective employer to make a determination regarding my suitability as an employee.

I further understand that, under the FCRA, in the event of Adverse Action, I may request a copy of any consumer report from the consumer reporting agency that compiled the report, after I have provided proper identification.

I agree that a copy of this authorization has the same effect as an original. Where permitted, this authorization shall remain in effect over the course of my employment and reports may be ordered periodically during the course of my employment.

Signature below verifies you have read the above notice and understand what it means.