Employment Application

PLEASE FULLY AND ACCURATELY COMPLETE

EACH QUESTION. INCOMPLETE APPLICATIONS

MAY NOT BE CONSIDERED.

Qualified applications receive equal consideration. No question is asked for the

purpose of excluding any applicant due to race, color, national origin ,religion,

age, sex, disability, or any other factor prohibited by law or regulation.

***** THIS COMPANY IS AN EQUAL OPPORTUNITY EMPLOYER *****

Date

Company

Referred By

Resume

Application Type

PERSONAL IDENTIFICATION

,

Please provide at least 1 phone number at which you can be contacted (NOT references)

,

Please provide additional addresses spanning the last 3 years

WORK PREFERENCE

Which position are you applying for?

OR

List any job benefits, other than wages, you expect or desire, in order of importance

Describe any prior experience, formal schooling, training, or skills related to your desired position

List any licenses, certificates, or professional affiliations you have

List any special skills you have (computers, machine operations, etc.)

List any hobbies, special interests, sports, or other activities in which you are involved

FOR DRIVING JOBS ONLY

Do you have a driver's license?

Have you had your driver's license suspended or revoked in the last 3 (three) years?

If yes, please explain

AVAILABILITY FOR WORK

Desired Work Schedule

Will you work extra days in the week if necessary?

Will you work overtime if necessary?

Are you now, or do you expect to be, engaged in any other employment, schooling, or other obligations that would affect your work schedule?

Do you have any other obligations or other commitments that would affect your work schedule?

PRESENT EMPLOYMENT

Are you presently employed?

If so, may we contact your present employer?

Do you need to give advance notice to your present employer if you are offered a position?

ELIGIBILITY

If requested, would you be willing to take a drug/alcohol screening exam before, and potentially after, employment as a condition of being hired and continued employment?

Are you at least 18 years old?

If hired, can you furnish proof that you are eligible to work in the United States?

PRIOR EVENTS

Have you ever worked for this company before?

Have you ever applied for work at this company before?

Have you ever been discharged with cause?

Have you ever been refused a surety bond or ever had one cancelled?

Have you ever been convicted of a law violation, except for minor traffic volations? (A criminal record does not automatically bar employment)

Have you ever been disciplined for absenteeism?

Have you ever been disciplined for tardiness?

Explanation to above

EDUCATION AND TRAINING

	School Name & Location	From	To	Received Diploma?	GPA	Major Subject(s)	Special Course(s)
High Shool or GED		NA
College
Graduate School
Other

PAST EMPLOYMENT

(Begin with your most recent position and work back)

DRIVING EXPERIENCE

	Dates
Equipment Class	From	To	Equipment Type	Approx. Total Miles
Straight Truck
Tractor & Semi Trailer
Tractor - Two-Trailers
Other

DOT Medical Card Expiration Date

List all states or foreign countries operated in for the last 5 (five) years

List all special courses and/or training completed (HazMat, PTD/DDC, etc.)

List any Safe Driving awards or other special certificates you hold and from whom

A) Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

B) Has any license, permit, or privilege ever been suspended or revoked?

D) Have you ever been convicted of a felony?

If you answered yes to A, B, or C, explain below

ACCIDENT RECORD FOR THE PAST 3 YEARS

TRAFFIC CONVICTIONS AND FORFEITURES

DRIVER'S LICENSES

Have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

IF YES - Have you successfully completed the return-to-duty process?

IF YES - Documentation MUST BE PROVIDED before any safety-sensitive transportation function is performed.

REFERENCES

TO BE READ AND SIGNED BY APPLICANT

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with CWR ("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken base in whole or in part on information obtained from FMCSA; the name, address, and toll free telephone number FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

AUTHORIZATION

The Prospective Employer may obtain such background reports, please read the following and sign below:

I Authorize CWR ("Prospective Employer") to access theFMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous thee (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer not the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.dmcsa/dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded to the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR% violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.

PLEASE READ AND SIGN BELOW

It is agreed and understood that any misrepresentation given on this application for qualification shall be considered an act of dishonesty.

I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me.

It is agreed and understood that if qualified to operate motor carrier equipment, I may be on a probationary period, during which I may be disqualified without recourse.

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.

AUTHORIZATION

In connection with your application for employment with CWR ("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken base in whole or in part on information obtained from FMCSA; the name, address, and toll free telephone number FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

TO BE READ AND SIGNED BY APPLICANT

Read carefully before sigining

By signing my name below, I attest that all information provided by me is true and correct to the best of my knowledge.

I understand omissions or misrepresentations may result in rejection of my application or, if employed, may result in subsequent dismissal. I hereby authorize any former employer, person, school, firm or corporation listed herein, including this company, to answer any and all questions related to employment and agree to release from liability and hold all persons harmless for giving any and all truthful information within their knowledge or records.

I understand this is a preliminary application and not a contract to employ me. Furthermore, in the event I am employed, my employment shall be completely voluntary and may be terminated at will at any time by either myself or the company. I understand that no one other than the company president has the authority to enter into any employment agreement to the contrary.

I agree to take a job-related physical examination and/or a drug/alcohol test when requested as a condition of employment. I agree to comply with all rules of the company as a condition of employment. In the event the company advances me money or other things of value, I agree to repay the company and also that any amount still owing may be deducted from my final paycheck.

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