Must meet all qualifications of section 391 and 383 of the Federal Motor Carrier Safety Regulations.
Age: Minimum of 24
Experience: 2 year of recent OTR tractor/trailer
No narcotic or other drug related convictions
No failures or refusals of Drug and Alcohol tests
No alcohol or drug related offenses
No leaving the scene of an accident

No driving while license is suspended or revoked
No reckless, negligent, or careless driving
No speeding in excess of 15 mph over the posted limit.
No Preventable D.O.T Recordable Accidents within the past 3 years
CSA/PSP Scores Pulled and Reviewed
Must submit to a pre-employment/pre-contract urine drug test with a negative result

Applicant Name

Applicant Email

Position(s) applied for

License Number

Do you have the legal right to work in the United States?
 yes no

Date of Birth

Phone Number


List Address of residency for past 3 years

Current Address

Current City

Current State

Current Zipcode

How long at Current Address?


Previous Address

Previous City

Previous State

Previous Zipcode

How long at Previous Address 1?


Previous Address

Previous City

Previous State

Previous Zipcode

How long at Previous Address 2?


Previous Address

Previous City

Previous State

Previous Zipcode

How long at Previous Address 3?


Have you worked for this company before?
 yes no

If Yes, where?

If Yes, reason for leaving?


Are you employed now?
 yes no

If not, how long since leaving last employment?


Who referred you?


Rate of Pay expected


Have you ever been bonded?
 yes no

If yes, Name of Bonding Company


Is there any reason you might be unable to perform the functions of the job for which you have applied?
 yes no

If yes, explain if you wish


EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.
Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.

(NOTE: list employers in reverse order starting with the most recent add another sheet if necessary.)

Employer Name

Employer Address

Employer City

Employer State

Employer Zipcode

Contact Name

Contact Number

Wage

Date worked (From-To)

Reason for Leaving

Were you subject to FMCSRs while employed?
 Yes No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
 Yes No


Employer Name

Employer Address

Employer City

Employer State

Employer Zipcode

Contact Name

Contact Number

Wage

Date worked (From-To)

Reason for Leaving

Were you subject to FMCSRs while employed?
 Yes No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
 Yes No


Employer Name

Employer Address

Employer City

Employer State

Employer Zipcode

Contact Name

Contact Number

Wage

Date worked (From-To)

Reason for Leaving

Were you subject to FMCSRs while employed?
 Yes No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
 Yes No


Additional Employers List here:


ACCIDENT RECORD FOR THE LAST 3 YEARS

Date

Nature of accident

Fatalities

Injuries

Hazardous release


Date

Nature of accident

Fatalities

Injuries

Hazardous release


Date

Nature of accident

Fatalities

Injuries

Hazardous release


TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS

Date

Location

Charge

Penalty


Date

Location

Charge

Penalty


Date

Location

Charge

Penalty


EXPERIENCE AND QUALIFICATIONS-DRIVERS (Please list State, License NO., Class, Endorsements, EXP Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
 yes no

B. Has any license, permit or privilege ever been suspended or revoked?
 yes no

If yes to either A. or B., give details


DRIVING EXPERIENCE

Class of Equipment

Straight Truck
 Yes No

TYPE of EQUIPMENT

Miles


Tractor/Trailer
 Yes No

TYPE of EQUIPMENT

Miles


Double/Triples
 Yes No

TYPE of EQUIPMENT

Miles


Motor Coach
 Yes No

TYPE of EQUIPMENT

Miles


List states operated in for the last five years:

Special training courses:


EXPERIENCE AND QUALIFICATIONS-OTHER

Show any trucking, transportation or other experience that may help in your work for the company:

List courses and training other than shown elsewhere in this application:

List special equipment or technical materials you can work with (other than those already shown):


EDUCATION

Highest grade completed

College

Last school attended


DRIVER APPLICANT DRUG AND ALCOHOL PRE-EMPLOYMENT STATEMENT

CFR Part 40.25(j) requires the employer to ask any applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, we must not use the employee to perform safety-sensitive functions, until and unless the potential employee provides documentation of successful completion of the return-to-duty process. (see section 40.25(b)(5)and(e).

As an applicant to perform safety sensitive functions for our company, you are required by CFR Part 40.25(j) to respond to the following questions.

1. 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?

 yes no

2. If you answered yes, to the above question, can you provide that you have successfully completed the DOT return- to-duty requirements?

 Yes NO


Pre-employment Urinalysis and Breath Analysis Consent Form

I understand that as required by the Federal Highway Administration Regulations, Title 49 Code of Federal Regulations Section 382.301, all driver-applicants of this employer must be tested for controlled substances and alcohol as a pre-condition for employment.

I consent to the urine sample collection and testing for controlled substances and the breath sample collection and testing for alcohol.

I understand that a verified positive test result for controlled substances and /or an alcohol concentration of 0.04 or higher will render me unqualified to operate a commercial motor vehicle.

The medical review officer will maintain the results of my controlled substance test. Negative and positive results will be reported to the employer. If the results are positive, the controlled substance will be identified.
Alcohol test results will be maintained by the employer.
The results will not be released to any other parties without my written authorization.
Understand the above conditions and hereby agree to comply with them.

REGARDING BACKGROUND REPORTS

FROM THE PSP Online Service

In connection with your application for employment with __JIM BENDER, INC__, it may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). 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 was based in part or in whole on this report. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain suck background reports, please read the following and sign below:

I authorize JIM BENDER, INC. to access the FMCSA 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 consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (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 nor 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.fmcsa.dot.gov. If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I have read the above Notice Regarding Background Reports provided to me by Jim Bender INC., and I understand that if I sign this consent form, Jim Bender INC may obtain a report of my crash and inspection history. I herby authorize Jim Bender INC and its employees, authorized agents, and/or affiliates to obtain the information authorized above.


TO BE READ AND SIGNED BY APPLICANT

I authorize Jim Bender Inc. to make such investigations and inquiries of 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 and after 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 interviews 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 49CFR 391.23(d) and (e). I understand that I have the right to:
• Review information provided by 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; 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.
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.

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the provisions of Section 604 (b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Reform Act of 1996 ( Title II, Subtitle D, Chapter 1, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

My digital signature below certifies that the information provided is true and correct and I agree with terms and conditions.

Applicants digital signature

Date