Become one of our drivers

Become One of Our Drivers

Name
 
 
 
Address
 
 
How Long?
Date of Birth
Social Security No
Hire Date
Telephone Number
E-Mail Address

PREVIOUS THERE YEARS RESIDENCY

Street
City
State & Zip Code
# Years
Street
City
State & Zip Code
# Years
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
Dates (From - To)
Approx. No. Of Miles (Total)
Class Of Equipment
Type of Equipment
Dates (From - To)
Approx. No. Of Miles (Total)
Class Of Equipment
Type of Equipment
Dates (From - To)
Approx. No. Of Miles (Total)
Class Of Equipment
Type of Equipment
Dates (From - To)
Approx. No. Of Miles (Total)

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE

Dates
Nature of Accident
Number of Fatalities
Number of Injuries
Chemical Spills
Dates
Nature of Accident
Number of Fatalities
Number of Injuries
Chemical Spills
Dates
Nature of Accident
Number of Fatalities
Number of Injuries
Chemical Spills

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS
(OTHER THAN PARKING VIOLATIONS)

Date Convicted (month/year)
Violation
State of Violation Location
Penalty
Date Convicted (month/year)
Violation
State of Violation Location
Penalty
Date Convicted (month/year)
Violation
State of Violation Location
Penalty
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
If yes, explain
Has any license, permit or privilege ever suspended or revoked?

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 there years (total of ten years employment record)

Last Employer

Name
Phone
Address (street number and name, city, state, and zip code)
Position Held
From
To
Salary
Reason for Leaving
Any gaps in employment and/or unemployment must explained. Include dates (month/year) and reason
Were you subject to the Federal Motor Center Safety Regulations (FMCSRs) white employed by the previous employer?
Was the previous job position designates 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?

Second Last Employer

Name
Phone
Address (street number and name, city, state, and zip code)
Position Held
From
To
Salary
Reason for Leaving
Any gaps in employment and/or unemployment must explained. Include dates (month/year) and reason
Were you subject to the Federal Motor Center Safety Regulations (FMCSRs) white employed by the previous employer?
Was the previous job position designates 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?

Third Last Employer

Name
Phone
Address (street number and name, city, state, and zip code)
Position Held
From
To
Salary
Reason for Leaving
Any gaps in employment and/or unemployment must explained. Include dates (month/year) and reason
Were you subject to the Federal Motor Center Safety Regulations (FMCSRs) white employed by the previous employer?
Was the previous job position designates 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?

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. (Generality, inquiries regarding medical history will be made only if and after of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability 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 perspective 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."
Applicants Signature
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.

Applicants Signature
Date

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

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

DISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES

Disclosure

A-1 Environmental Inc. (the "Company") may request from a consumer reporting agency and for employmentrelated purposes, a "consumer report(s)" (commonly known as "background reports") containing background information about you in connection with your employment, or application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable).

The background report(s) may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. The types of background information that may be obtained include, but are not limited to: criminal history; litigation history; motor vehicle record and accident history; social security number verification; address and alias history; credit history; verification of your education, employment and earnings history; professional licensing, credential and certification checks; drug/alcohol testing results and history; military service; and other information.

Authorization

I hereby authorize A-1 Environmental Inc. to obtain the consumer reports described above about me.

Applicant Name
Applicant Signature
Date