Employment Application

Contact Information

Name:

Company:

Hire Date:

Address 1:

Address 2:

Years at Address:

City:

State:

Zip Code:

Country:

Phone:

Date of Birth:

SSN:

E-mail:

 

Previous Residency

Street:

City:

State:

Zip Code:

# Years:

 

Previous Residency

Street:

City:

State:

Zip Code:

# Years:

 

Previous Residency

Street:

City:

State:

Zip Code:

# Years:

 

License Information

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

State:

License #:

Type:

Expiration:

 

Driving Experience

Straight Truck

Equipment Type:

Date (From)

Date (To):

Number of Miles:

 

Tractor & Semi-Trailer

Equipment Type:

Date (From)

Date (To):

Number of Miles:

 

Tractor & Two Trailers

Equipment Type:

Date (From)

Date (To):

Number of Miles:

 

Other

Equipment Type:

Date (From)

Date (To):

Number of Miles:

 

Accident Record

Please include incidents for the past three (3) years or more.

Accident 1

Date of Accident:

Nature of Accident:

Fatality Number:

Injury Number:

Chemical Spills:

 

Accident 2

Date of Accident:

Nature of Accident:

Fatality Number:

Injury Number:

Chemical Spills:

 

Accident 3

Date of Accident:

Nature of Accident:

Fatality Number:

Injury Number:

Chemical Spills:

 

Traffic Convictions and Forfeitures

Please include incidents for the past three (3) years or more (other than parking violations).

Traffic Conviction 1

Date of Conviction:

Violation:

State:

Penalty:

 

Traffic Conviction 2

Date of Conviction:

Violation:

State:

Penalty:

 

Traffic Conviction 3

Date of Conviction:

Violation:

State:

Penalty:

 

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

If yes, please explain:

 

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

If yes, please explain:

 

Employment Record

Applicants that desire to drive in intrastate/interstate commerce must provide the following information 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.) You must list the complete mailing address: street number and name, city, state and zip code.

Last Employer:

Address:

Phone:

Position Held:

Start Date:

End Date:

Salary:

Reason For Leaving:

 

Any gaps in employment must be explained. Include Dates (Month/Year) and reason.

 

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

 

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

 

Second Last Employer:

Address:

Phone:

Position Held:

Start Date:

End Date:

Salary:

Reason For Leaving:

 

Any gaps in employment must be explained. Include Dates (Month/Year) and reason.

 

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

 

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

 

Third Last Employer:

Address:

Phone:

Position Held:

Start Date:

End Date:

Salary:

Reason For Leaving:

 

Any gaps in employment must be explained. Include Dates (Month/Year) and reason.

 

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

 

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

 

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 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
  • 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.

 

Name:

Date:

 

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.

Name:

Date:

 

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

 

 

Our Location


Alfredo Trucking, Inc.
Mailing Address:
P.O. Box 276; Annapolis Junction, MD 20701

Physical Address:
8900 Corridor Road; Annapolis Junction, MD 20701
Telephone:301-497-4111
Cell:443-829-7676
FAX:301-497-4114
E-mail:alfredotrucking@verizon.net
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