Drivers Application for Employment

Name

First

Last

Social Security Number

The U.S. Department of Transportation requires that driver applicants give their date of birth (§391.21(b)(2)

Present Address (Street Address, City, State, Zip)

Phone Number

Email Address

If at the above residence for less than three years, list your addresses of residency for the past three years. If the included fields below are not enough room, please add the remainder of addresses in the notes box at the bottom of this application.

Previous Address (Street Address, City, State, Zip)

Previous Address (Street Address, City, State Zip

Are you legally eligible to work in the United States?

Yes

No

Have you ever been convicted of or plead guilty to any felony?

Yes

No

If yes, please explain fully. Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.

Is there any reason you might be unable to perform the functions of the job for which you have applied. If yes, please explain.

Company Experience

Have you ever worked for this company before? If so, please list dates and reason for leaving.

If not, when was your last day employed?

Rate of Pay and Position Held

General

Are you currently employed? If not, when was your last day employed?

Who referred you?

Have you ever been bonded? If so, include name of bonding company.

Educational Experience

Highest Grade Completed

College

1

2

3

4

Last school attended (Name & City/State)

Area of Study (if any specified)

Employment Experience

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.

*Includes vehicles having a GVWR of 26001 lbs. or more, vehicles designed to transport 16 or more passengers, including the driver, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to
transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Present or Last Employer

Address (Include Street Address, City, State, Zip)

Supervisor Name & Job Title

Supervisor Phone Number

Dates of Employment (Include From/To Dates, and Month/Year)

Were you subject to the FMCSA regulations 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

Reason for Leaving

2nd Employer

Address (Include Street Address, City, State, Zip)

Supervisor Name & Job Title

Supervisor Phone Number

Dates of Employment (Include From/To Dates, and Month/Year)

Were you subject to the FMCSA regulations 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

Reason for Leaving

3rd Employer

Address (Include Street Address, City, State, Zip)

Supervisor Name & Job Title

Supervisor Phone Number

Dates of Employment (Include From/To Dates, and Month/Year)

Were you subject to the FMCSA regulations 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

Reason for Leaving

4th Employer

Address (Include Street Address, City, State, Zip)

Supervisor Name & Title

Supervisor Phone Number

Dates of Employment (Include From/To Dates, and Month/Year)

Were you subject to the FMCSA regulations 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

Reason for Leaving

5th Employer

Address (Include Street Address, City, State, Zip)

Supervisor Name & Title

Supervisor Phone Number

Dates of Employment (Include From/To Dates, and Month/Year)

Were you subject to the FMCSA regulations 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

Reason for Leaving

6th Employer

Address (Include Street Address, City, State, Zip)

Supervisor Name & Title

Supervisor Phone Number

Dates of Employment (Include From/To Dates, and Month/Year)

Were you subject to the FMCSA regulations 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

Reason for Leaving

7th Employer

Address (Include Street Address, City, State, Zip)

Supervisor Name & Title

Supervisor Phone Number

Dates of Employment (Include From/To Dates, and Month/Year)

Were you subject to the FMCSA regulations 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

Reason for Leaving

8th Employer

Address (Include Street Address, City, State, Zip)

Supervisor Name & Title

Supervisor Phone Number

Dates of Employment (Include From/To Dates, and Month/Year)

Were you subject to the FMCSA regulations 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

Reason for Leaving

Driver Experience & Qualification

Any drivers licenses held in the last 7 years must be shown

State

License Number

Class

Endorsement

Expiration Date

State

License Number

Class

Endorsement

Expiration Date

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

Yes

No

If yes, please explain.

Has any license, permit, or privilege ever been suspended or revoked?

Yes

No

If yes, please explain.

Have you ever tested positive or refused a drug or alcohol pre-employment test within the past 3 years from any DOT regulated employer who did not hire you?

Yes

No

If yes, please explain.

Driving Experience

Straight Truck

Yes

No

Type of Straight Truck

Date From/Date To (Include Month/Year)

Approximate Number of Miles Total

Tractor & Semi-Trailer

Yes

No

Type of Tractor & Semi-Trailer

Date From/Date To (Include Month/Year)

Approximate Number of Miles Total

Tractor & Two Trailers

Yes

No

Type of Tractor & Two Trailers

Date From/Date To (Include Month/Year)

Approximate Number of Miles Total

Motor Coach – School Bus

Yes

No

Amount of Passengers

Date From/Date To (Include Month/Year)

Approximate Number of Miles Total

List states operated in during the last 5 years:

Additional Work Experience/Special Skills

List special courses or trainings that will help you as a driver:

Which safe driving awards do you hold and from whom?

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

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

Accident Record

List any accidents in the last 7 years

Date of Last Accident

Nature of Accident (Head-On, Rear-End, Etc.)

Were there fatalities?

Yes

No

Were there injuries?

Yes

No

Hazardous Material Spill?

Yes

No

Were you cited?

Yes

No

Next Previous

Nature of Accident (Head-On, Rear-End, Etc.)

Were there fatalities?

Yes

No

Were there injuries?

Yes

No

Hazardous Material Spill?

Yes

No

Were you cited?

Yes

No

Next Previous

Nature of Accident (Head-On, Rear-End, Etc.)

Were there fatalities?

Yes

No

Were there injuries?

Yes

No

Hazardous Material Spill?

Yes

No

Were you cited?

Yes

No

Traffic Convictions & Forfeitures

Include everything other than parking convictions for the last 7 years.

Date, Location, Charge, & Penalty

Job applicants for the position of driver for Hell Bent Xpress must be able to perform these essential job functions safely:

1. Climb into and out of the cab of a conventional semi tractor.
2. Must be able to visually inspect engine water levels and dip stick oil levels on the tractor’s engine during their daily and pre-trip inspections.
3. Climb onto the top of a tank trailer in order to open dome cover for loading and unloading procedures.
4. Must be able to assist in the hand unloading or loading of a van or a refer trailer.
5. Must be able to climb into the back of a live bottom trailer to move product around for unloading. And for the adjustment of tarp covers.
6. Must be able to shift a manual transmission on a semi-tractor.
7. Must be able to safely operate tractor foot pedals (Clutch, brake, and accelerator pedal).
8. Must have a current Commercial Drivers License (CDL) with proper endorsements.
9. Must have a current DOT physical.
10. Must pass a pre-employment drug screen test.

TO BE READ AND SIGNED BY APPLICANT

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

BY APPLICANT

In the event of employment, I understand that false or misleading information given in my application or interview may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company.
I understand the 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 49 CFR 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.

I certify that I have read and understood all of this employment application. It is agreed and understood that the employer or his agents, may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons named herein from all liability for any damages on account of furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the results of a physical examination, drug test, and/or motor vehicle record.

I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.
I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of the employer.

I understand that I will be required, prior to hire, to provide proof of eligibility to work in the United States and information on any relevant criminal convictions.

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.

By typing my name below, I express my understanding and consent of the abovementioned items.

Name

First

Last

Date