Job Application, MSJC Logistics

Job Application

Name *

First

Middle

Last

Date of Birth *

Phone Number *

Social Security Number or Tax ID Number *

Email *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Driver's License Number *

Type or Class *

License Issuer State *

Endorsements *

Expiration Date *

Detail your Experience: *

Please explain your driving history (haul type, number of trailers, miles driven, equipment used (type and class), and dates as a driver)

Accident Record (Past Three Years) *

Please explain any accidents in the past three years (nature of the accident, fatalities, injuries, and chemical spills). If no accidents in the past three years exist, please use N/A.

Traffic Convictions and Forfeitures (Past Three Years) *

Please list the conviction date, the violation, the state the violation occurred in, and the penalty. If no violations in the past three years, please use N/A.

Have you ever been denied a license, permit, or privilege to operate a vehicle? *

Has any license ever been suspended or revoked *

If yes, please explain in the box below

Please explain if the answer to the above question was "Yes":

Most Recent Employer Name *

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards.

Employer Phone *

Employer Address *

Please enter street address, city, state, zip

Position Held *

From *

To *

Reason for Leaving (If not currently employed)

Salary *

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *

Please answer yes or no

Please answer yes or no *

Was the job designated as a safety sensitive function in any Department of Transportation regulated mode subject to all alcohol or controlled substances testing as regulated by 49 CFR, part 40?

Second Most Recent Employer Name *

Employer Phone *

Employer Address *

Please enter street address, city, state, zip

Position Held *

From *

To *

Reason for Leaving (If not currently employed)

Salary *

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *

Please answer yes or no

Please answer yes or no *

Was the job designated as a safety sensitive function in any Department of Transportation regulated mode subject to all alcohol or controlled substances testing as regulated by 49 CFR, part 40?

Third Most Recent Employer Name

Employer Phone

Employer Address

Please enter street address, city, state, zip

Position Held

From

Reason for Leaving (If not currently employed)

Salary

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Please answer yes or no

Was the job designated as a safety sensitive function in any Department of Transportation regulated mode subject to all alcohol or controlled substances testing as regulated by 49 CFR, part 40?

Education: Name and Location of Last High School Attended *

Years Completed

Graduated?

Please answer yes or no

Details

Education: Name and Location of Last College Attended

Course of Study

Years Completed

Graduated?

Please answer yes or no

Details

Education: Name and Location of Other Training/Qualifications

Course of Study

Years Completed

Graduated/Completed?

Please answer yes or no

Details

To be read and digitally signed by applicant. *

Please type your name in the box if you accept this statement as this is your electronic signature. I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and release information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to review information provide by current/previous employers; have errors in the information corrected by previous employers, and for those previous employers to resend 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 information. This certifies that I have completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require and applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

Date of your submission *