COMMERCIAL DRIVER EMPLOYMENT APPLICATION

APPLICATION FOR EMPLOYMENT - COMMERCIAL DRIVER

Jeff Martin Transportation, Inc. is an Equal Opportunity Employer. All qualified candidates will receive consideration for employment without regards to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status or any other characteristic protected by law.
PERSONAL INFORMATION
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Have you lived here longer than 3 years?

YesNo
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
SSN*

Driver's License Information: All licenses held, last 3 years

	State	Driver License Number	Expiration Date
1
2
3

Driving Experience

	Type of Vehicle Driven	Start Date	End Date	Appx Miles Driven
1
2
3

Have you been in an accident in the past 3 years?*

Have you been convicted in a traffic violation in the past 3 years?*

List all Traffic Violation Convictions, last three years.

	Date	Violation	State	Commercial Vehicle
1
2
3

Have you ever had any driver license denied, suspended, revoked, or canceled by any issuing state agency?*
If yes, state of issuance and explanation.
EDUCATION

Please indicate education or training which you believe qualifies you for the position you are seeking.
High School
Name of High School*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Phone Number*

Area CodePhone Number
High School: Number of Years Completed *
Diploma*
G.E.D.*
College/Vocational/Training
Name of College/Vocational School
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Phone Number

Area CodePhone Number
Did you graduate?
Additional Training and/or Degree
Name of School
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Phone Number

Area CodePhone Number
Did you graduate?
Skills
Equipment
Computer
Office
Other
Professional License or Membership

You do not need to disclose membership in professional organizations that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry, age, disability, marital status, veteran status or any other protected status.)
Type of License (s) Held
Other Professional Memberships
EMPLOYMENT HISTORY

List employers from the past ten (10) years with most current employer first, including U.S. Military Service
May we contact your present employer?*
If any employment was under a different name, indicate name
Employer*
Employment Dates
Employment Type
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
Reason for leaving*
Employer
Employment Dates
Employment Type
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
Reason for leaving
Employer
Employment Dates
Employment Type
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
Reason for leaving
Do you need to added additional employers?
Additional Employment Information
Employer
Employment Dates
Employment Type
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
Reason for leaving
Employer
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
Employment Dates
Employment Type
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
Reason for leaving
Employer
Employment Dates
Employment Type
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
Reason for leaving

Controlled Substance and Alcohol Questionnaire Pursuant to 49 CFR part 40.25(j).
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 (2) years?*
If yes, documentation MUST BE PROVIDED before any safety-sensitive transportation function is performed. Have you successfully completed the return-to-duty process?

REFERENCES
Professional References
Personal Reference

For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL), the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).

As a prospective driver employee, you have the right to review information provided by previous employers. you have the right to have errors in the information corrected by the previous employer(s) and for that previous employers(s) to re-send the corrected information to the prospective employers; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer provided investigative information, must submit a written request to the prospective employer, which may be don at anytime, including when applying or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet reached the requested information from the previous employer(s), then the five (5) business day deadlines will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.
If yes, please provide name(s) and relationship(s).
How did you learn about this job opening?*

FacebookIndeedLinkedInWalk-InReferralOther
Explain any gaps in work history:
Do you have friends and/or relatives working for Jeff Martin Auctioneers, Inc.? *
Have you ever been discharged or asked to resign from a job? *
If yes, please explain:
Are you legally eligible for employment in the United States? (Proof of identity will be required to provide authorization to work.)*

NOTIFICATION OF DRIVER APPLICANT’S RIGHTS

REGARDING SAFETY PERFORMANCE HISTORY INVESTIGATIONS

According to 391.21(d) and 391.23 (i) the prospective employer must expressly notify drivers with the Department of Transportation regulated employment during the preceding three years that he or she has the following rights regarding the investigative information that will be provided to the prospective employer.
- The right to review information provided by previous employer;
- The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer;
- The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified if denial of employment. The prospective employer must provide this information to the applicant within (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer (s), then the five-business day’s deadline will begin when the prospective employer receives the requested safety performance history information. The driver has not arranged to pick up or receive the requested records within (30) days of the prospective employer making them available. The prospective motor carrier may consider the driver to have waived his/her request to review the records. For the requirements of drivers and employers regarding these requests see 391.23 (j).

SAFETY PERFORMANCE HISTORY INVESTIGATION-PREVIOUS USDOT REGULATED EMPLOYERS

DRIVER APPLICANT RELEASE

Please complete one form for each previous USDOT regulated employer for three (3) years.

I hereby specifically you to release the following information to Jeff Martin Transportation and their agents for the purpose of investigation as required by 391.23 and 40.321(b) of the Federal Motor Carrier Safety Regulations. You are hereby released from any and all liability which may result from furnishing such information.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Applicant's Name*

First NameLast Name
SSN:*
Previous Employer/ Company Name:*
Phone Number

Area CodePhone Number
Fax:
Employment Dates:
PREVIOUS EMPLOYER: In accordance with 49 CFR 40.25 and 391.23, we are hereby requesting that you supply us with the Safety Performance History if this individual. under DOT rule 391.23(g) you must respond to this inquiry within 30 days of receipt.

1. Are the dates of employment correct as stated above?

___YES ___NO
If no, please provide the correct dates of employment:_________________________

2. Did the applicant drive commercial motor vehicles for your company?

___YES ___NO
3. Was the applicant a safe and efficient driver?

___YES ___NO
4. Was the applicant involved in any vehicle accidents while employed with your company?

___YES ___NO
If yes, please provide details below.

5. Reason for leaving your employment:

___Resignation ___Discharged ___Lay off
6.Has the applicant tested positive for a controlled substance in the last three (3) years?

___YES ___NO
7. Has the applicant had an alcohol test with a B.A.C of 0.04 or greater in the last three (3) years?

___YES ___NO
8. Has the applicant refused a required test for drugs or alcohol in the last three (3) years?

___YES ___NO
9. Did the applicant complete a substance abuse rehabilitation program, if required?
___YES ___NO

If yes, please provide documentation of the employee’s successful completion of DOT return to duty requirements

10. Has this person ever violated any other DOT agency drug or alcohol testing?
___YES ___NO

Comments:_______________________________________________________

_______________________________________________________________

________________________________________________________________
Name (Please Print):_____________________________ Title: ____________

Signature:_____________________________________ Date:_____________

SAFETY PERFORMANCE HISTORY INVESTIGATION-PREVIOUS USDOT REGULATED EMPLOYERS

DRIVER APPLICANT RELEASE

Please complete one form for each previous USDOT regulated employer for three (3) years.

I hereby specifically you to release the following information to Jeff Martin Transportation and their agents for the purpose of investigation as required by 391.23 and 40.321(b) of the Federal Motor Carrier Safety Regulations. You are hereby released from any and all liability which may result from furnishing such information.
Applicant's Signature

Clear
Applicant's Name

First NameLast Name
SSN:
Previous Employer/ Company Name:
Address:
Phone Number

Area CodePhone Number
Fax:
Employment Dates:
PREVIOUS EMPLOYER: In accordance with 49 CFR 40.25 and 391.23, we are hereby requesting that you supply us with the Safety Performance History if this individual. under DOT rule 391.23(g) you must respond to this inquiry within 30 days of receipt.

1. Are the dates of employment correct as stated above?

___YES ___NO
If no, please provide the correct dates of employment:_________________________

2. Did the applicant drive commercial motor vehicles for your company?

___YES ___NO
3. Was the applicant a safe and efficient driver?

___YES ___NO
4. Was the applicant involved in any vehicle accidents while employed with your company?

___YES ___NO
If yes, please provide details below.

5. Reason for leaving your employment:

___Resignation ___Discharged ___Lay off
6.Has the applicant tested positive for a controlled substance in the last three (3) years?

___YES ___NO
7. Has the applicant had an alcohol test with a B.A.C of 0.04 or greater in the last three (3) years?

___YES ___NO
8. Has the applicant refused a required test for drugs or alcohol in the last three (3) years?

___YES ___NO
9. Did the applicant complete a substance abuse rehabilitation program, if required?
___YES ___NO

If yes, please provide documentation of the employee’s successful completion of DOT return to duty requirements

10. Has this person ever violated any other DOT agency drug or alcohol testing?
___YES ___NO

Comments:_______________________________________________________

_______________________________________________________________

________________________________________________________________

Name (Please Print):_____________________________ Title: ____________

Signature:_____________________________________ Date:_____________

SAFETY PERFORMANCE HISTORY INVESTIGATION-PREVIOUS USDOT REGULATED EMPLOYERS

DRIVER APPLICANT RELEASE

Please complete one form for each previous USDOT regulated employer for three (3) years.

I hereby specifically you to release the following information to Jeff Martin Transportation and their agents for the purpose of investigation as required by 391.23 and 40.321(b) of the Federal Motor Carrier Safety Regulations. You are hereby released from any and all liability which may result from furnishing such information.
Applicant's Signature

Clear
Applicant's Name

First NameLast Name
SSN:
Previous Employer/ Company Name:
Address:
Phone Number

Area CodePhone Number
Fax:
Employment Dates:
PREVIOUS EMPLOYER: In accordance with 49 CFR 40.25 and 391.23, we are hereby requesting that you supply us with the Safety Performance History if this individual. under DOT rule 391.23(g) you must respond to this inquiry within 30 days of receipt.

1. Are the dates of employment correct as stated above?

___YES ___NO
If no, please provide the correct dates of employment:_________________________

2. Did the applicant drive commercial motor vehicles for your company?

___YES ___NO
3. Was the applicant a safe and efficient driver?

___YES ___NO
4. Was the applicant involved in any vehicle accidents while employed with your company?

___YES ___NO
If yes, please provide details below.

5. Reason for leaving your employment:

___Resignation ___Discharged ___Lay off
6.Has the applicant tested positive for a controlled substance in the last three (3) years?

___YES ___NO
7. Has the applicant had an alcohol test with a B.A.C of 0.04 or greater in the last three (3) years?

___YES ___NO
8. Has the applicant refused a required test for drugs or alcohol in the last three (3) years?

___YES ___NO
9. Did the applicant complete a substance abuse rehabilitation program, if required?
___YES ___NO

If yes, please provide documentation of the employee’s successful completion of DOT return to duty requirements

10. Has this person ever violated any other DOT agency drug or alcohol testing?
___YES ___NO

Comments:_______________________________________________________

_______________________________________________________________

________________________________________________________________

Name (Please Print):_____________________________ Title: ____________

Signature:_____________________________________ Date:_____________

REQUEST FOR CHECK OF DRIVING RECORD

DRIVER APPLICANT

I hereby authorize you to release the following information to Jeff Martin Transportation and their agents for the purpose of investigation as required by 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. If hired, I authorize an annual check of my motor vehicle record as required by 391.25 of the Federal Motor Carrier Safety Regulations. You are hereby released from any and all liability which may result from furnishing such information.
Applicants Signature

Clear
Date

MonthDayYear
Date
MOTOR CARRIER
In accordance with the provisions of sections 604 and 607 of the Fair Credit Reporting Act, Public law 51-908, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), I hereby certify the following:

1. The consumer (applicant) has authorized in writing the procurement of this report.

2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for the employment process.
3. The information requested below will be used for a “permissible purpose” (i.e., information for employment purposes) and will be used for no other purpose;
4. The information being obtained will not be used in violation of the federal or state equal opportunity law or regulation; and
5. Before taking an adverse action based in a whole or in a part on the report the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency.
I also hereby certify that this report request and the above applicant’s release notice meet the definition of “permissible uses” of the state motor vehicle records under the provisions of the Driver’s Privacy Act Of 1994 (Public Law 103-322, Title XXX, Section 300002(a).

Requester's Signature: _____________________________ Date:___________

Printed Name:________________________________

Requester' Company: Jeff Martin Transportation LLC

Address: PO Box 16809 Hattiesburg MS 39404

The following named person has made application with our company for the position of __________________. In accordance with 391.23 of the U.S. Dept of Transportation Regulations, please furnish the above signed with the applicant’s driving record for the past (3) years.
Name of Applicant/ Employee:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
SSN:*
Driver's License No:*
Driver's License State:*

CERTIFICATE OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

MOTOR CARRIER REQUIREMENTS

The requirements of Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle with a GVWR of 26,0001 lbs. Or more, can transport (16) or more people, or transport hazardous material that require placarding.

The requirements of Part 383 apply to every driver who operates in interstate commerce and operates a vehicle with GVWR of 10,0001 lbs. Or more can transport (9) or more people, or transport hazardous material that require placarding.

DRIVER REQUIREMENTS

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

1. Must Possess Only One License:

You, as a commercial motor vehicle driver, may not possess more than one motor vehicle operator’s license.

If you have more than one license, keep the license for your state of residence and return the additional license to the state that issues 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, close your record by notifying the state of issuance that you no longer want to be licensed by the state.

2. Notification of License Suspension, Revocation, or Cancellation:

Section 391.15(b)(2) and 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 addington Section 383.31 requires that any time you violate a state or local traffic law (other than parking violation), you must report it within 30 days to: 1.Your employing motor carrier, and
2. The state that issued you license (if the violation occurs out of state other than the one which issued your license). The notification to both the employer and state must be written.
The following license is the only one I will possess:

Driver's License No:* State:*
Expiration: Date*
I hereby certify that I have read and agree to the above stated requirements.*

Driver's First NameDriver's Last Name
Driver's Signature*

Clear
Date*

MonthDayYear
Date

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Jeff Martin Transportation (“Prospective Employer”) 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 authorizing the release of safety performance information including crash data from the previous five (5) years of 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 capability to correct any safety or data that appears to be incorrect. I understand that I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa,dot,gov. If I challenge a crash or inspection information reported by a State, FMCSA cannot change or correct data. I understand my request will be forwarded by 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. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure an dAuthorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employers and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Date*

MonthDayYear
Date
Signature*

Clear
Printed Name:*

First NameLast Name

IMPORTANT - PLEASE READ AND SIGN

I certify 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. I understand that failure to reveal any prior employer, or giving false or misleading information by me on any part of this Application for Employment can result in disqualification for employment consideration or, if hired, may be grounds for termination from the company or its' subsidiaries. I understand that if I am hired, my employment is for no definite time and may be terminated at any time without prior notice.
Signature*

Clear

   FMCSA does not require that motor carrier employers subject to the Agency’s drug

and alcohol use and testing regulations in 49 CFR Part 382 use this format to obtain an employee’s consent to conduct a limited/Full query of the Drug and Alcohol

Clearinghouse. Employers may, however, use or adapt the content as they see fit.

General Consent for Limited/Full Queries of the Federal Motor Carrier Safety Administration

(FMCSA)Drug and Alcohol Clearinghouse

I,  First Name*   Last Name* , hereby provide consent to Jeff Martin Transportation to conduct a limited/Full query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse.

I,  First Name*   Last Name* , consent to Unlimited limited/Full queries for the duration of my employment.

The scope of this consent would be determined by the employer.

I understand that if the limited query conducted by Jeff Martin Transportation LLC, indicates that drug or

alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose

that information to Jeff Marion Transportation LLC, without first obtaining additional specific consent

from me.

I further understand that if I refuse to provide consent for Jeff Martin Transportation LLC, to conduct a

limited query of the Clearinghouse, Jeff Martin Transportation LLC, may prohibit me from performing

safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.

  Employee Signature *   Date*
Should be Empty:

	Date	Short description of Accident	Facilities	Injuries
1
2
3

APPLICATION FOR EMPLOYMENT - COMMERCIAL DRIVER

PERSONAL INFORMATION

EDUCATION

High School

College/Vocational/Training

Additional Training and/or Degree

Skills

Professional License or Membership

EMPLOYMENT HISTORY

Additional Employment Information

Controlled Substance and Alcohol Questionnaire Pursuant to 49 CFR part 40.25(j).

REFERENCES

Professional References

Personal Reference

For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL), the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).

The following license is the only one I will possess:

Driver's License No:* State:* Expiration: Date*

AUTHORIZATION

IMPORTANT - PLEASE READ AND SIGN

Driver's License No:* State:*
Expiration: Date*