Application for Hire

* I understand that the information in this application will be used and that prior employers and carriers to who I have leased equipment will be contacted for purposes of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations.

** The information given on this application will be treated as strictly confidential. It shall be necessary for the applicant to answer each and every question completely, clearly and accurately.

*** Please fill in all date fields as DD/MM/YYYY. Please allow yourself 30-40 minutes to fill out this job application correctly.

* First Name:

* Last Name:

* Date:

Address:

* Street:

* City:

* Province/State

* ZIP/Postal Code:

* Country:

Contact Information:

* Your Email:

* Phone Number:

Cell:

Personal Information

* Date of Birth:

* Social Insurance number:

Fast Card number:

Previous Addresses

* Address 1:

* How long did you live at this address:

Address 2:

How long did you live at this address:

Emergency Contact

* Name:

* Phone number:

* Relationship:

* Please describe any positions, jobs or duties for which you should not be considered because of physical, medical or mental disabilities (if none, please type N/A):

* Have you been granted a waiver under Section 391.49 of the Federal Motor Carrier Safety pertaining to loss of foot, leg, hand or arm?:

Driving Experience

I've driven a Straight Truck from:
to for approximately miles.

I've driven a Tractor & Semi-trailer from:
to for approximately miles.

I've driven a B-Trans from:
to for approximately miles.

I've driven other forms of transport equipment from:
to for approximately miles.

What States & Provinces have you operated within over the last five years? (ex: NS, NB, PE, NY, MA, FL)

Education

* Highest grade completed (please check):
Grade School
* Do you have any post-secondary or graduate education?
 Yes  no

Name of school:

Address:

Special Courses or training that will help you as a driver:

Driver Training

* Driver Training School:

* Year Graduated:

* Safe driving awards that you hold, and what company?

General Information:

* Have you ever been charged with a criminal offense for which you have not received a pardon?
 yes  no
* Have you ever worked for this company under another name?
 yes  no

Personal History for the Past 10 Years

* The Department of Transportation requires that at least three years employment be shown and/or commercial driving experience for past 10 years be shown. "See Resume" is not acceptable. Leave no blanks or gaps in time. Application can not be processed without employer phone numbers.

Last Employer:

Company Address:

Supervisor:

Position Held:

Phone:

From
To
Was this position designated as safety sensitive and subject to drug and alcohol testing requirements of 49 CFR Part 40?
 yes  no
May we contact your present carrier and/or employer?
 yes  no

Last Employer:

Company Address:

Supervisor:

Position Held:

Phone:

From
To
Was this position designated as safety sensitive and subject to drug and alcohol testing requirements of 49 CFR Part 40?
 yes  no
May we contact your present carrier and/or employer?
 yes  no

Last Employer:

Company Address:

Supervisor:

Position Held:

Phone:

From
To
Was this position designated as safety sensitive and subject to drug and alcohol testing requirements of 49 CFR Part 40?
 yes  no
May we contact your present carrier and/or employer?
 yes  no

Last Employer:

Company Address:

Supervisor:

Position Held:

Phone:

From
To
Was this position designated as safety sensitive and subject to drug and alcohol testing requirements of 49 CFR Part 40?
 yes  no
May we contact your present carrier and/or employer?
 yes  no

Last Employer:

Company Address:

Supervisor:

Position Held:

Phone:

From
To
Was this position designated as safety sensitive and subject to drug and alcohol testing requirements of 49 CFR Part 40?
 yes  no
May we contact your present carrier and/or employer?
 yes  no

Last Employer:

Company Address:

Supervisor:

Position Held:

Phone:

From
To
Was this position designated as safety sensitive and subject to drug and alcohol testing requirements of 49 CFR Part 40?
 yes  no
May we contact your present carrier and/or employer?
 yes  no

Violation and Review

Traffic convictions and forfeitures for the past five (5) years (other than parking violations):

Location:

Date:

Fine:

Penalty/Charge:
Location:

Date:

Fine:

Penalty/Charge:
Location:

Date:

Fine:

Penalty/Charge:
Location:

Date:

Fine:

Penalty/Charge:

* 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

* C. Have you ever been disqualified subject to section 391 of the Federal Motor Carrier Safety Regulations?
 yes  no
If the answer to either A, B, or C is YES, please describe below:

Accident Review for the Past Five (5) Years

Date of Accident:

$$ Amount:

Fatalities:

Injuries:

Nature of Accident (head-on, rear-end, upset, etc.):

Date of Accident:

$$ Amount:

Fatalities:

Injuries:

Nature of Accident (head-on, rear-end, upset, etc.):

Date of Accident:

$$ Amount:

Fatalities:

Injuries:

Nature of Accident (head-on, rear-end, upset, etc.):

Medical Declaration

On March 30, 1999 United States Federal Motor Carrier Safety Regulation medical requirements for Canadian drivers of commercial motor vehicles operating in the United States were revised.

I acknowledge there is no requirement for a completed United States medical fitness report.

This revision does require that a Canadian driver must comply with the medical requirements of the province in which their commercial driver's license is issued and that a medical fitness report if completed on the frequency as required by license issuing province.

I, certify that under the new revisions of the medical requirement to operate a commercial motor vehicle in the United States, that I am not impaired to operate a commercial motor vehicle by any of the following:

* A. I have no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control (administered by injection).
 yes  no
* B. I have no established medical history or clinical diagnosis of epilepsy.
 yes  no
* C. I have no impaired hearing, first perceives a forced whispered voice in the better ear at not less than five feet with or without use of a hearing aid when the audiometric device is calibrated to American National Standard (formerly ASA Standard) Z24.5-1951.
 yes  no
* D. I also agree to inform the company should my medical status change, and if any of the above impairments are subsequently diagnosed to the level of affecting my fitness to operate a commercial motor vehicle in the United States.
 yes  no

Statement of Previous Testing - Employment Not Obtained

The information requested is pursuant to US DOT regulation 49 CFR Part 40.49 CFR Part 40, Subpart B, Section 40.25(j) states: As the employer, you must ask the employee 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 testing rules during the past three years.

* Have you ever tested positive or refused to test on any pre-employment drug and alcohol test administered by an employer where you applied for, but did not obtain, safety-sensitive work covered by US DOT agency drug and alcohol testing rules during the past two years?
 yes  no

If you answered "yes", please provide information that you have successfully completed the DOT return-to-duty requirements, including company name, address and date of test/refusal.

Company Name:

Address:

Date of Test/Refusal to test:

Certificate of Compliance

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a drier must comply with. These requirements are in effect as of July 1, 1987. They are as follows:

You, as a commercial vehicle driver, may not possess more than one license. The only exception is if a state requires you to have more than one license. This exception is allowed until January 1, 1990. If you currently have more than one license, you should keep the license from your state of residence and return the additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen or destroyed, you should close your record by notifying the state of issuance that you no longer want to be licensed by that state.

Part 392.42 and Part 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Part 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it to your employing motor carrier and the state that issued your license within 30 days.

Certification By Driver

I hereby certify that I have read and understand the driver provisions of the Commercial Motor Vehicle Safety Act of 1986, which becomes effective on July 1, 1997.

* License #:

* Province/State:

* Type/Class:

I further certify that the above commercial vehicle license is the only one held; or that I have surrendered the following licenses to the province/state indicated.

License #:

Province/State:

Type/Class:

Driver Data Information

Instructions: Motor carriers when using a driver for the first time or intermittently shall obtain from the driver a signed statement giving the total time on duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8 (r) Federal Motor Carrier Safety Regulations.

* Month/Year:

* Day of Week:
1: Hours per day:
2: Hours per day:
3: Hours per day:
4: Hours per day:
5: Hours per day:
6: Hours per day:
7: Hours per day:
* TOTAL HOURS:

* DRIVER CERTIFICATION: I certify that I have read and understand the above requirements. And I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at:


* Time:

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