APPLICATION FOR QUALIFICATION : PERSONAL

Name:
Address (Street, City, State, Zip):
Phone:

If at the above residence less than 3 years, list below all residences for the past 3 years.
PREVIOUS ADDRESS

Address (Street, City, State, Zip):
Address (Street, City, State, Zip):
Address (Street, City, State, Zip):

Date of Birth ( / / ):
Social Security:

EMERGENCY INFORMATION

In Case of Emergency Notify (Name):
Phone:
Address (Street, City, State, Zip):

Position Applying for:
Type of work:	Full Time Part Time Temporary
Who referred you?
Have you worked for this company?	yes no
	If yes, from to
Where?
Rate of Pay?
Position:
Reason for leaving?
Have you ever worked for this company under another name?	yes no
	If yes,
Have you ever been bonded?	yes no
Name of bonding company
List names of relatives working for this company
Are you currently employed?	yes no
If not, how long since leaving last employment?

APPLICATION FOR QUALIFICATION: EMPLOYMENT RECORD
Complete all data for EACH last employer COMPLETELY. The U.S. Department of Transportation requires that the driver applicants show all employment for the past three years. Effective July 1, 1987, they must also show commercial driver employment for the seven years preceding this three year period. Sec. 391.21 (b) (10) (11). Account for any gaps in employment between employers.

LAST EMPLOYER:

Employer Name:
Address (Street, City, State, Zip):
Phone:
Position Held:
Dates:	to
Where you regulated by FMCSA during this job?	yes no
Areas Driven In:
Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?	yes no
Reasons for Leaving:

SECOND LAST EMPLOYER:

Employer Name:
Address (Street, City, State, Zip):
Phone:
Position Held:
Dates:	to
Where you regulated by FMCSA during this job?	yes no
Areas Driven In:
Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?	yes no
Reasons for Leaving:

THIRD LAST EMPLOYER:

Employer Name:
Address (Street, City, State, Zip):
Phone:
Position Held:
Dates:	to
Where you regulated by FMCSA during this job?	yes no
Areas Driven In:
Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?	yes no
Reasons for Leaving:

FOURTH LAST EMPLOYER:

Employer Name:
Address (Street, City, State, Zip):
Phone:
Position Held:
Dates:	to
Where you regulated by FMCSA during this job?	yes no
Areas Driven In:
Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance & alcohol testing?	yes no
Reasons for Leaving:

 

APPLICATION FOR QUALIFICATION: DRIVER EXPERIENCE & QUALIFICATION
LICENSES List all licenses held in the last 3 years.

State:
License Number:
Type/Endorsements:
Expiration Date:

State:
License Number:
Type/Endorsements:
Expiration Date:

State:
License Number:
Type/Endorsements:
Expiration Date:

Do you currently hold more than one valid license?	yes no
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
In the last 2 years have you tested positive or refused a pre-employment drug test for a motor carrier that did not hire you?	yes no
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Reg’s?	yes no

If answered Yes to any of the above questions, please give details:

Class of Equipment:
Type (Van, Tank, Etc.):
Dates:

Class of Equipment:
Type (Van, Tank, Etc.):
Dates:

Class of Equipment:
Type (Van, Tank, Etc.):
Dates:

List states operated in during last five years:
List safe driving awards held & who presented by

ACCIDENT REVIEW FOR PAST 3 YEARS

Date:		City, State:
# of Fatalities:		# of Injuries:

Nature of Accident (Head-on, Rear-end, etc.):

Date:		City, State:
# of Fatalities:		# of Injuries:

Nature of Accident (Head-on, Rear-end, etc.):

MOTOR VEHICLE LAWS & ORDINANCES for the past 3 years other than parking violation:

Date:		Location:
Charge:		Penalty:

Date:		Location:
Charge:		Penalty:

Date:		Location:
Charge:		Penalty:

Applicant: Read and sign before submitting this application.
It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty and reason for non-consideration or subsequent dismissal if hired or denial of authorization to drive. It is also agreed and understood that the motor carrier or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his/her furnishing such information. I understand that nothing contained in this application or in the granting of any interview or a road test is intended to create an employment contract between this company and myself, for either employment, authorization to driver, or for the providing of any benefits. No promises regarding employment or authorization to drive have been made to me, and no such promises exist unless specifically made by this Company in writing. It is agreed and understood that if qualified, hired or contract started, I may be on a probationary period during which time I may be disqualified without recourse. I understand employment or authorization to drive with this carrier is on an “at-will” basis that allows me to quit, be fired, or lease agreement revoked at any time with or without notice and with or without cause.

Signature:
Date:

By signing this document, 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.

I agree

APPLICATION FOR QUALIFICATION

Applicant: Read and sign before submitting this application.
By this document, HARRY H. LONG MOVING STORAGE & EXPRESS discloses to you that a consumer report, including an investigative report containing information as to your character, general reputation, personal characteristics, driving record, and mode of living may be obtained for employment purposes as part of the pre-employment background investigation and at any time during your employment. Should an investigation consumer report be requested you have the right to demand a complete and accurate disclosure of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act. Please sign below to signify receipt of the foregoing disclosure.

I agree to furnish such additional information that may be necessary and complete such examinations as may be required to complete my application file including but not limited to a pre-employment negative urine test and successful completion of a human performance evaluation including a Department of Transportation Physical.

Signature:
Date:

By signing this document, 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.	I agree