APPLICATION FOR EMPLOYMENT
 
First Name Middle Name Last Name
Email Phone    
Address City State
Zip How LONG?    
PREVIOUS ADDRESS IF CURRENT ADDRESS IS LESS THAN 3 YEARS:
Address City State
Zip How LONG?    
Address City State
Zip How LONG?    
Date of birth Social security number    
DRIVER LICENSES HELD (PAST 3 YEARS)
LICENSE NUMBER TYPE STATE EXPIRATION DATE
HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE? Yes   No
HAS ANY LICENSE, PERMIT, OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED? Yes   No

 

TRAFFIC CONVICTIONS/FORFEITURES FOR THE PAST 3 YEARS (other than Parking violations)
DATE

LOCATION

CHARGE

PENALTY

 

ACCIDENT RECORD FOR THE PAST 8 WARS OR MORE (use additional sheet if necessary)

DATE

NATURE OF ACCIDENT(BEAD-ON, REAR-END, UPSET, ETC.

INJURIES

FATALITIES
EXPERIENCE AND QUALIFICATIONS OF DRIVER
CLASS OF EQUIPMENT
(CHECK YES OR NO)
CHECK TYPE OF EQUIPMENT DATES
FROM (M/Y)    TO (M/Y)		 APPROXIMATE TOTAL MILES
Straight Truck Yes No
Van Tank Flat Dump Refer
Tractor/Semi-Trailer Yes No
Van Tank Flat Dump Refer
Tractor/Two-Trailers Yes No
Van Tank Flat Dump Refer
Tractor/Three-Trailers Yes No
Van Tank Flat Dump Refer
Bus/School Bus Yes No
Van Tank Flat Dump Refer
Entry Level Driver Training (less than one year experience) Yes No
Date of Certification
Longer Combination Vehicle (LCV) Training Yes No
Date of Certification

EMPLOYMENT HISTORY

NOTE: THE REGULATIONS REQUIRE THAT EMPLOYMENT FOR AT LEAST 3 YEARS AND/OR COMMERCIAL DRIVING EXPERIENCE FORTHE PAST 10 YEARS BE SHOWN. THE PREVIOUS EMPLOYERS MAY BE CONTACTED AS PART OF THE HIRING PROCESS.

  Name  From Date    To Date 
  Address  Position Held   
  City   State  Zip 
Salary/Wage   
 Contact Person  Phone 
 Reason For Leaving 
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED? Yes   No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE (COMMERCIAL DRIVER) SUBJECT TO THE FMCSR, PARTS 40 AND 3S2? Yes   No
 
  Name  From Date    To Date 
  Address  Position Held   
  City   State  Zip 
Salary/Wage   
 Contact Person  Phone 
 Reason For Leaving 
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED? Yes   No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE (COMMERCIAL DRIVER) SUBJECT TO THE FMCSR, PARTS 40 AND 3S2? Yes   No
 
  Name  From Date    To Date 
  Address  Position Held   
  City   State  Zip 
Salary/Wage   
 Contact Person  Phone 
 Reason For Leaving 
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS WHILE EMPLOYED? Yes   No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE (COMMERCIAL DRIVER) SUBJECT TO THE FMCSR, PARTS 40 AND 3S2? Yes   No
 
PREVIOUS PRE-EMPLOYMENT ALCOHOL AND CONTROLLED SUBSTANCES TESTING
* To Be Completed By Prospective Employee * *
THE FOLLOWING REQUESTED INFORMATION IS REQUIRED BY FEDERAL MOTOR CARRIER SAFETY REGULATION, TITLE 49, PART 40.25(J).

PLEASE READ THE FOLLOWING INFORMATION VERY CAREFULLY AND ANSWER THE QUESTIONS TO THE BEST OF YOUR KNOWLEDGE. FAILURE TO COMPLETE THIS QUESTIONNAIRE PRECLUDES ANY CHANCE OF EMPLOYMENT WITH THIS COMPANY

RELATIVE TO PRE-EMPLOYMENT SUBSTANCE ABUSE AND ALCOHOL MISUSE TESTING, AS A POTENTIAL EMPLOYEE APPLYING FOR A POSITION AS A COMMERCIAL MOTOR VEHICLE OPERATOR WITH ANY MOTOR CARRIER EMPLOYER, IN THE PAST TWO YEARS HAVE YOU:
 
TEST POSITIVE FOR SUBSTANCE ABUSE? Yes No
TREFUSED A SUBSTANCE ABUSE TEST? Yes No
TESTED POSITIVE FOR AN ALCOHOL MISUSE TEST? Yes No
REFUSED AN ALCOHOL MISUSE TEST? Yes No
IF YOU HAVE ANSWERED "YES" TO ANY ONE OF THE ABOVE QUESTIONS YOU SST PROVIDE THE FOLLOWING INFORMATION (FMCSR, PART 40, SUBPART 0):
YOUR SUBSTANCE ABUSE PROFESSIONAL (SAP):
Name      Phoner Number  
Address     
City          State  Zip 
• COPY OF YOUR SAP PROGRAM CERTIFYING COMPLETION OF ALL REQUIREMENTS OR
• COPY OF YOUR SAP PROGRAM AND
• COPY OF YOUR RETURN-TO-DUTY NEGATIVE TEST RESULT AND
• COPY OF ALL YOUR FOLLOW-UP TESTS ADMINISTERED IN COMPLIANCE WITH YOUR SAP PROGRAM.
I CERFITY THAT THE ABOVE INFORMATION PROVIDED BY ME IS TRUE AND CORRECT
Print Name Signature
Social Security Number Date
   
REQUEST/CONSENT FOR INFORMATION FROM PREVIOUS EMPLOYER

TME INFORMATION REQUESTED IS REQUIIIED BY FEDERAL MOTOR CARRIER SAFETY REGULATIONS, TITLE 49, SECTIONS 40.25 AND 391.23

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE
To           Date:              
Address  Re:                
City          Sate  Zip SSE#:             
Period Of Employment  Position Held: 
I HEREBY AUTHORIZED YOU TO RELEAS/VERIFY ALL INFORMATION REGARDING MY IDENTIFICATION, EMPLOYMENT HISTORY, CHARACTER, CONDUCT, ALCOHOL AND CONTROLLED SUBSTANCES TESTING, AND ACCIDENT RECORD FOR THE PAST 3 YEARS TO:
Prospective Employer   
Attention                      Phone 
Street                           Fax    
City          Sate  Zip
IN COMPLIANCE WITH FMCSR §40.25(G) AND §391.23(H), RELEASE OF THIS INFORMATION MUST BE MADE IN A WRITTEN FORM THAT ENSURES CONFIDENTIALITY, SUCH AS FAX, EMAIL, OR LEITER. UNDER FMCSR 391.23(G), YOU MUST RESPOND wrrni 30 DAYS OF RECEIPT.

SECTION 2: PREVIOUS EMPLOYER TO COMPLETE AS IT PERTAINS TO FMSCR SECTION 40.25 / 891.28

IF DRIVER/EMPLOYEE WAS NOT SUBJECT TO §382 TESTING REQUIREMENTS WHILE EMPLOYED BY THIS EMPLOYER, PLEASE CHECK HERE , SIGN AT THE BOTTOM AND SKIP TO THE NEXT SECTION (Over),

HAS THIS PERSON VIOLATED ANY OF THE DRUG AND/OR ALCOHOL PROHIBITIONS UNDER FMCSR §40 OR §382 IN THE PAST THREE YEARS, INCLUDING:
 1. A controlled substance test result of positive, adulterated, or substituted (FMCSR §382.215) Yes   No
 2. An alcohol test with a result of 0.04 or higher alcohol concentration (FMCSR §382.201) Yes   No
 3. A refusal to submit to a random, post-accident, reasonable suspicion, or follow-up controlled substance or alcohol test (FMCSR §382.211) Yes   No
 4. Has this person committed other violations if Subpart B of 382, or Part 40? Yes   No
 5. If this person violated a DOT drug and/or alcohol prohibition, did he/she fail to begin or complete a rehabilitation program prescribed by a Substance Abuse Professional (SAP)? If rehabilitation was required but you do not know if he/she began or completed such program check here .               Yes   No   N/A
 6. If this person successfully completed a SAP's rehabilitation referral and remained in your employ, did he/she subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refusal to be tested?              Yes   No   N/A
COMPLETED BY
SECTION 3: PREVIOUS EMPLOYER TO COMPLETE AS IT PERTAINS TO FMCSR SECTION

APPLICANT'S ACCIDENT RECORD FOR THE PREVIOUS 3 YEARS
DATE OF ACCIDENT LOCATION
CITY / STATE		 NUMBER OF INJURIES NUMBER OF FATALITIES HAZARDOUS MATERIALS ELEASED
(Other Than Fuel From Fuel Tanks)
Yes   No
Yes   No
SECTION 4: APPLICANTS PERFORMANCE HISTORY
QUALITY OF WORK  EXCELLENT  GOOD  FAIR  POOR
CO-OPERATION WITH OTHERS  EXCELLENT  GOOD  FAIR  POOR
SAFETY  EXCELLENT  GOOD  FAIR  POOR
DRIVING SKILLS  EXCELLENT  GOOD  FAIR  POOR
ATTENDANCE RECORD  EXCELLENT  GOOD  FAIR  POOR
Why did applicant leave? 
Would you re-hire? 
Did applicant have custody of money or valuables? 
Was Driver's License ever suspended or revoked? 
COMMENTS  
COMPLETED BY  
   
Driver Statement of On-Duty Hours
(For Newly Hired Drivers)
INSTRUCTIONS: MOTOR CARRIERS WHEN USING A DRIVER FOR THE FIRST TIME SHALL OBTAIN FROM THE DRIVER A EOM STATEMENT PINE THE TOTAL TIME ON-DUTY DIMINO THE WIED/ATELY PRECEDINO 7 DAYS AND TIME AT WHICH SUCH DRIVER WAS LAST RELIEVED FROM DUTY PRIOR TO BEGINNING WORK FOR SUCH CARRIER. SECTION 395.8(J) (2) OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS. NOTE: HOURS FOR ANY COMPENSATED WORK DURING THE PRECEDING 7 DAYS, INCLUDING WORK FOR A NON-MOTOR CARRIER ENTITY, MUST BE RECORDED ON THIS FORM.
 
DRIVER NAME (PRINT)  
SOCIAL SECURITY No   TYPE OF LICENSE  
LICENSE No   ISSUING STATE  
DAY 1 2 3 4 5 6 7 TOTAL HOURS
DATE  
HOURS WORKED
I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at on
Driver Certification For Other Compensated Work

INSTRUCTIONS: WHEN EMPLOYED BY A MOTOR CARRIER, A DRIVER MUST REPORT TO THE CARRIER ALL ON-DUTY TIME, INCLUDING TIME WORKING FOR OTHER EMPLOYERS. THE DEFINITION OF ON-DUTY TIME FOUND IN SECTION 395.2(8)(9) OF

THE FEDERAL MOTOR CARRIER SAFTY REGULATIONS INCLUDES TIME PERFORMING ANY OTHER WORK IN THE CAPACITY OF, OR IN THE EMPLOY OR SERVICE OF, A COMMON, CONTRACT OR PRIVATE MOTOR CARRIER, ALSO PERFORMING ANY COMPENSATED WORK FOR ANY NON-MOTOR CARRIER ENTITY .
 Are you currently working for another employer Yes   No
  Do you intend to work for another employer while employed with this company? Yes   No
I HEREBY CERTIFY THAT THE INFORMATION GIVEN ABOVE IS TRUE AND I UNDERSTAND THAT ONCE
I BECOME EMPLOYED WITH THIS COMPANY, IF I BEGIN WORKING FOR ANY ADDITIONAL EMPLOYER (5) FOR COMPENSATION THAT I MUST INFORM THIS COMPANY IMMEDIATELY OF SUCH EMPLOYMENT ACTIVITY.
 SIGNATURE  Date 
Permission to Obtain DMV Reports
 Name of Job Applicant/Employee 
 Street Address 
City          State  Zip  Date
Wildwood Express Inc
P.O Box 397
 Kingsburg, CA 93631

Dear Wildwood Express Inc.:

Department of Motor Vehicle reports may be obtained as part of the Wildwood Express Inc. evaluation of my job application/employment. The reports may be procured by DlBuduo & DeFendis Insurance Agency, and may include my driving record, to assess my insurability under the Company's insurance coverage's. By signing this disclosure, I hereby authorize the Company to procure such reports about me from time to time, as it deems appropriate, to evaluate my insurability.

Sincerely,
 
License#                        
Date of Birth                   
 
 

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