Welcome to your Driver Application
Name (First, Middle, Last):
Address:
Date of Birth:
SSN:
Telephone Number:
Cell Phone Number:
List Any Previous Addresses For The Past 3 Years:
State
License Number
Type
Expiration Date
Type of Equipment (Van, Tank, Flat, etc.):
Dates from and to:
Approximate Number of Miles (Total):
(Date, Nature of Accident, Fatalities, Injuries):
List: Location, date, charge, and penalty.
Have you ever been convicted of a Felony, DUI or DWI?
If yes, please explain:
Has any license, permit or privilege ever been suspended or revoked?
Have you ever tested positive for drugs and/or alcohol?
(List ALL past employment for the last three years and ALL DOT regulated past employers for the past 10 years)
Name of Employer:
Phone Number/Fax Number
Address, City, State
Position Held:
Reason for Leaving:
Were you subject to U.S. DOT drug & alcohol testing?
Was this employer regulated by U.S. DOT?
Phone Number/Fax Number:
Clicking the box certifies that this application and any additional past employer records have been completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Applicant Name:
Date:
In connection with my application for employment (including contract for services), I understand that consumer reports or investigative consumer reports which may contain public record information may be requested or made on me including consumer credit, criminal records, driving record, education, prior employer verification, workers compensation claims and others. These reports will include experience along with reason for termination of past employment. Further, I understand that you will be requesting information from various Federal, State and Local Agencies, which may contain my past activities. I hereby authorize without reservation, any pa1ty or agency contacted by this employer to furnish the above-mentioned information.I understand that I have the right to make a request of the Consumer Reporting Agency, upon proper identification and the payment of any authorized fees, the information in its files on me at the time if my request. I further authorize ongoing procurement of the above-mentioned reports at any time during my employment (or contract).
Full Name
Maiden
Address (Street, City, State, Zip):
Years in Residence:
Social Security Number:
Previous Address (Street, City, State, Zip):
Driver's License State and License Number:
Race:
Sex:
Name:
Date
**Completion of this form is optional prior to extension of a verbal employment offer, however, it may delay start date with Ace Grease Service, Inc.
Applicant's Name:
Name of Applicant:
Dates of Employment (from and to):
Was the job full-time or part-time?
Position(s) Held:
Was the job local, regional, or over-the-road?
Did this driver operate commercial motor vehicles greater than 26,000 lbs GVWR?
Type of equipment operated:
Other (please list):
If terminated, why?
Eligible For Rehire?
Accident Date
City, State
Did the accident involve...
Brief description of what happened:
Brief description of what happened
Has this driver ever had a breath alcohol test, within the past 3 years, a result of 0.04 or higher alcohol concentration?
Has this driver ever had a positive drug test in the past 3 years?
Has this driver refused a controlled substance test and/or alcohol test within the past 3 years?
Has this driver violated any other DOT drug/alcohol regulation?
If yes, please explain the violation:
Have you ever received information from a previous employer that this driver violated any DOT drug and alcohol regulations?
If yes, please provide details below including the reason for the test and the result of the test:
If the applicant tested positive, to your knowledge, have they satisfactorily completed all return to duty and follow-up testing requirements in accordance 49 CFR 382.503?
Any other remarks:
Verification completed by (include your title):
Phone number:
Verification Date:
Applicant's Name
Driver's License Number and State
Time's up
