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Driver Application

 

FIRST Name:
MIDDLE Name:
LAST Name:
Social Security #:
 Date of Birth:
 Height:
 Weight:
Address:
City:
State:
Zip Code:
PHONE#:
EMAIL Address:
Referred by:

Addresses for the past 3 YEARS If different from current address

PREVIOUS ADDRESS

Address:
City:
State:
Zip Code:
How Long?:

PREVIOUS ADDRESS 2

Address:
City:
State:
Zip Code:
How Long?:

High School Name:
Years Attended:

Year of Graduation:
Driving School Name:
Did you Graduate?:

Grade Point Average?:

percent

Have you Worked for GREGORY Before?:

Have you ever Driven a Vehicle (Tractor/Trailer, Other truck, Van, Auto, Etc.) For an Employer in the past 3 years?

Have you ever been denied Bonding?

Have you ever Been Fired from a Job?

Are you presently Unemployed?:

Do you have the legal right to work in the United States?

Please give us details of your work experience. Include school or other training programs, Military Service, and self Employment. Please List Employment of the LAST 10 YEARS. Be very sure to completely fill out all blanks

Present or Last Employer

Dates of Employment: From to 
Company Name:
Contact Name:
Address:
City:
State:
ZIP:
Phone Number:
Salary/Wage:
# of States Driven in:
Reason for Leaving:

 

Unemployed?: From to 

Previous Employer 2

Dates of Employment: From to 
Company Name:
Contact Name:
Address:
City:
State:
ZIP:
Phone Number:
Salary/Wage:
# of States Driven in:
Reason for Leaving:

 

Unemployed?: From to 

Previous Employer 3

Dates of Employment: From to 
Company Name:
Contact Name:
Address:
City:
State:
ZIP:
Phone Number:
Salary/Wage:
# of States Driven in:
Reason for Leaving:

 

Unemployed?: From to 

Previous Employer 4

Dates of Employment: From to 
Company Name:
Contact Name:
Address:
City:
State:
ZIP:
Phone Number:
Salary/Wage:
# of States Driven in:
Reason for Leaving:

 

Unemployed?: From to 

Previous Employer 5

Dates of Employment: From to 
Company Name:
Contact Name:
Address:
City:
State:
ZIP:
Phone Number:
Salary/Wage:
# of States Driven in:
Reason for Leaving:

 

Unemployed?: From to 

Previous Employer 6

Dates of Employment: From to 
Company Name:
Contact Name:
Address:
City:
State:
ZIP:
Phone Number:
Salary/Wage:
# of States Driven in:
Reason for Leaving:

 

Unemployed?: From to 

List All Drivers Licenses that you have held in the Past 3 Years

License 1

License #:
State:
Type:
Expiration Date:

License 2

License #:
State:
Type:
Expiration Date:

License 3

License #:
State:
Type:
Expiration Date:

List All traffic convictions for the Past 3 Years (in ANY Motor vehicle, other than parking violations)

Conviction 1

Date:
State:
Violation: (if speeding, show rate of speed)
Penalty or Amt of Fine:

Conviction 2

Date:
State:
Violation: (if speeding, show rate of speed)
Penalty or Amt of Fine:

Conviction 3

Date:
State:
Violation: (if speeding, show rate of speed)
Penalty or Amt of Fine:

List All involvements with any vehicle for the Past 3 Years (even if not at fault).

Accident 1

Date:
Commercial Vehicle?:

Type of Accident:
Where you at Fault?:

Were you Ticketed?:

Injuries/Fatalities?:

Accident 2

Date:
Commercial Vehicle?:

Type of Accident:
Where you at Fault?:

Were you Ticketed?:

Injuries/Fatalities?:

Accident 3

Date:
Commercial Vehicle?:

Type of Accident:
Where you at Fault?:

Were you Ticketed?:

Injuries/Fatalities?:

 

Are you physically able, with or without reasonable accommodation:

To Operate a commercial motor vehicle for long periods of time?:

to shove freight weighing up to 75lbs or more per piece, frequently, a distance of up to 53 Feet, for periods of time?

to climb in and out of an over-the-road tractor, 4 to 6 feet, 8 to 10 times per day?

to reach, push and/or pull above shoulder level, to load or unload freight for periods of time?

to complete written logs and expense records?

to conduct pre-trip inspections of a tractor and trailer?

to fuel and perform minor maintenance on a tractor and trailer?

to do map reading, basic math, reading and writing?

 

Has any License, permit or privilege ever been suspended or Revoked?             

Date
Have you ever been convicted of reckless driving, careless driving, or careless operation of a motor vehicle, or are any charges pending?

Date
Have you ever been convicted for driving while under the influence of alcohol, a narcotic drug, marijuana, amphetamines, or derivatives thereof, or are any charges pending?

Date
Have you ever been convicted for possession, sale, or transfer of a narcotic drug, marijuana, amphetamines, or derivatives thereof, or are any charges pending?

Date
If you answered YES to any question immediately above, Please explain

To be read and signed by applicant

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.

I authorize you to make such investigations and inquiries of my personal, employment, financial and other related matters as may be necessary in arriving at an employment decision. Specifically, I understand that consumer reports may be requested from DAC Services. These reports may include the following types of information: previous employers, dates of service, reason for termination, accidents, etc. I further understand that such reports may contain from federal, state or other agencies, information concerning my driving record, criminal record, workers’ compensation claims, etc. I hereby release employers, schools, healthcare providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. I further authorize TLC to release any and all information regarding myself to any of its lessees that TLC may consider assigning me to.

You have the right to review information provided to us by your previous employers and have any errors in such information corrected by your previous employer as stated in section 391.23 (i) of the FMCSRs. Should you wish to review this information you must submit a written request to us, your prospective employer, as stated in section 391.23 (i) of the FMCSRs.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. understand, also, that I am required to abide by all rules and regulations of the Company.

 By checking this box, I consent to my physical signature and certify that the information is true and correct.

RELEASE & CONSENT FORM USIS/DAC SERVICES

PART 1 – DOT DRUG AND ALCOHOL RELEASE

I authorize, per 49 CFR Part 40, the release of information from my DOT regulated drug and alcohol testing records by my previous employers to USIS for the sole purpose of transmitting such records to The TLC Companies and its representatives/agents/clients. I authorize the release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of drug and alcohol rule violation(s); and (vi) documents, if any, of completion of return-to-duty process following a rule violation. I hereby authorize my worksite employer to submit copies of my current and future drug test results to the TLC Companies. This authorization shall expire if and when my worksite employer is no longer a client of the TLC Companies.

The information I have authorized USIS to review involves tests required by the DOT. If any carrier/company/school for whom I was previously employed furnishes USIS with information concerning items (i) through (vi) above, I also authorize that carrier/company/school to release and furnish the dates of my negative drug and/or alcohol tests with results below 0.04 during the three-year period and the name and phone number of any substance abuse professionals who evaluated me during the past three years.

 By checking this box, I consent to my physical signature and certify that the information is true and correct.

PART 2 – CONSUMER REPORT DISCLOSURE AND RELEASE

In connection with your employment or application for employment (including contract for services), consumer reports may be requested from USIS Commercial Services or other Consumer Reporting Agencies ("CRA"). These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, and drugs/alcohol use. Such reports may contain public record information concerning your driving record, workers’ compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from USIS concerning previous driving record requests made by others from such state agencies and state provided driving records.

You have the right to make a request to CRA, upon proper identification, to request the nature and substance of all information in its file son you at the time of your request, including the sources of information and the recipients of any reports on you that USIS has previously furnished within the three-year period preceding your request. The TLC Companies may be contacted by mail at 325 S. Calumet Road, Suite 1, Chesterton Indiana, 46304, or by phone at (800) 926-8440.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTRACTED BY CRA, TO FURNISH THE ABOVE-MENTIONED INFORMATION. THIS AUTHORIZATION DOES NOT APPLY TO DRUG AND ALCOHOL INFORMATION OBTAINED UNDER PART 1.

I hereby consent to your obtaining the above information from CRA, and I agree that such information which CRA has or obtains, and my employment history (not Drug and Alcohol information without a specific consent by me) with you if I am hired, will be supplied by CRA to other companies which subscribe to CRA. I hereby authorize procurement of consumer report(s). If hired or contracted this authorization, for Part 2 reports only, shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment or contract period.

 

 By checking this box, I consent to my physical signature and certify that the information is true and correct.

Press And your Request will be processed or to start again.