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3400 2nd Ave South Birmingham, AL 35222
205.251.4060
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Employment Application
Name
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
TO BE READ AND SIGNED BY APPLICANT
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or inter view(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
I understand that information 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.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Position(s) Applied For
Add
Remove
Name
(Required)
First
Middle
Last
SSN
(Required)
List your addresses of residency for the past 3 years.
Current Address
(Required)
Same as previous
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
How Long?
Previous Addresses
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
How Long?
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
How Long?
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
How Long?
Do You Have The Legal Right To Work In The United States?
(Required)
Yes
No
Date Of Birth
(Required)
MM slash DD slash YYYY
(Required for Commercial Drivers)
Can You Provide Proof Of Age
(Required)
Yes
No
Have You Worked For This Company Before?
(Required)
Yes
No
Previous Experience
Where?
(Required)
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Rate Of Pay
(Required)
Position
(Required)
Reason For Leaving
(Required)
Are You Now Employed?
(Required)
Yes
No
How Long Since Leaving Last Employment?
(Required)
Who Referred You?
Rate Of Pay Expected
(Required)
Have You Ever Been Bonded?
Yes
No
(Answer only if a job requirement)
Name Of Bonding Company
(Required)
Have You Ever Been Convicted Of a Felony?
(Required)
Yes
No
Please Explain
(Required)
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 [as described in the attached job description]?
(Required)
Yes
No
Explain if you wish
Employment History
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 addi tional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
Employer
Name
(Required)
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Position Held
Salary
Contact Person
Contact Phone
Reason For Leaving
(Required)
Were You Subject To The FMCSRs† While Employed?
(Required)
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?
(Required)
Yes
No
More Employment History?
(Required)
Yes
No
Employer
Name
(Required)
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Position Held
Salary
Contact Person
Contact Phone
Reason For Leaving
(Required)
Were You Subject To The FMCSRs† While Employed?
(Required)
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?
(Required)
Yes
No
More Employment History?
(Required)
Yes
No
Employer
Name
(Required)
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Position Held
Salary
Contact Person
Contact Phone
Reason For Leaving
(Required)
Were You Subject To The FMCSRs† While Employed?
(Required)
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?
(Required)
Yes
No
More Employment History?
(Required)
Yes
No
Employer
Name
(Required)
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Position Held
Salary
Contact Person
Contact Phone
Reason For Leaving
(Required)
Were You Subject To The FMCSRs† While Employed?
(Required)
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?
(Required)
Yes
No
*Includes vehicles having a GVWR of 26,001 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.
Accident history for the past 3 years
(Required)
Date
Nature of accident <br> (head-on, rear-end, upset, etc)
Fatalities
Injuries
Hazardous material spill
Add
Remove
If none, write none. Click the plus sign on the right if more than 1.
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
(Required)
Location
Date
Charge
Penalty
Add
Remove
If none, write none. Click the plus sign on the right if more than 1.
Experience and Qualifications - Driver
List all driver licenses or permits held in the past 3 years
(Required)
State
License No.
Type
Expiration Date
Add
Remove
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
(Required)
Yes
No
Has any license, permit or privilege ever been suspended or revoked?
(Required)
Yes
No
Please Provide Details
(Required)
Class of equipment
(Required)
Straight Truck
Tractor and semi-trailer
Tractor - two trailers
Tractor - three trailers
Motorcoach - School Bus (more than 8 passengers)
Motorcoach - School Bus (more than 15 passengers)
Other
Straight Truck
Type of equipment
Van
Tank
Flat
Dump
Refer
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Approximate total number of miles
(Required)
Tractor and semi-trailer
Type of equipment
Van
Tank
Flat
Dump
Refer
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Approximate total number of miles
(Required)
Tractor - two trailers
Type of equipment
Van
Tank
Flat
Dump
Refer
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Approximate total number of miles
(Required)
Tractor - three trailers
Type of equipment
Van
Tank
Flat
Dump
Refer
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Approximate total number of miles
(Required)
Motorcoach - School Bus (more than 8 passengers)
Type of equipment
Van
Tank
Flat
Dump
Refer
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Approximate total number of miles
(Required)
Motorcoach - School Bus (more than 15 passengers)
Type of equipment
Van
Tank
Flat
Dump
Refer
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Approximate total number of miles
(Required)
Other
Type of equipment
Van
Tank
Flat
Dump
Refer
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Approximate total number of miles
(Required)
List States Operated in For Last 5 years
(Required)
Add
Remove
Click plus sign to the right to add more than 1
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
Experience and Qualifications - Other
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)
Education
Please indicate highest form of education completed
Last School Attended
City, State
TO BE READ AND SIGNED BY APPLICANT
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
Signature
Date
MM slash DD slash YYYY