DUNCAN & SON LINES
23860 W. HWY 85, BUCKEYE, AZ 85326
PHONE: 800-528-4283 / FAX: 623-386-8734
DRIVER APPLICATION FOR EMPLOYMENT
Applicant: You are advised that the information you provide in this application may be used, and your prior employers will be contacted for the purpose of investigating your background as required by D.O.T. regulation parts 382 thru 391.
/ /
/ /
/ /
/ /
/ /
LICENSE AND DRIVING RECORD
Do you hold more than one valid driver’s license? (choose one):
Please list all licenses issued to you in the last three years.
List all traffic convictions&accidents within the last three years.
DRIVING EXPERIENCE:
What types of trailers have you pulled? (check all that apply):
EMPLOYMENT HISTORY
(List ALL employers for the past 10 years)
/
/
/
/
During your employment, were you subject to Federal Motor Carrier Safety Regulations and/or was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40? (choose one):
/
/
/
/
During your employment, were you subject to Federal Motor Carrier Safety Regulations and/or was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40? (choose one):
/
/
/
/
During your employment, were you subject to Federal Motor Carrier Safety Regulations and/or was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40? (choose one):
/
/
/
/
During your employment, were you subject to Federal Motor Carrier Safety Regulations and/or was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40? (choose one):
/
/
/
/
During your employment, were you subject to Federal Motor Carrier Safety Regulations and/or was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40? (choose one):
/
/
/
/
During your employment, were you subject to Federal Motor Carrier Safety Regulations and/or was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40? (choose one):
/
/
/
/
During your employment, were you subject to Federal Motor Carrier Safety Regulations and/or was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40? (choose one):
/
/
/
/
During your employment, were you subject to Federal Motor Carrier Safety Regulations and/or was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40? (choose one):
/
/
/
/
During your employment, were you subject to Federal Motor Carrier Safety Regulations and/or was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40? (choose one):
/
/
/
/
During your employment, were you subject to Federal Motor Carrier Safety Regulations and/or was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40? (choose one):
TO BE READ BY APPLICANT
APPLICANT’S STATEMENT AND AGREEMENT: As a condition of my employment, I hereby certify that all the information I have provided on this application is true and correct. If at any time after employment has been established it is discovered that I misrepresented or falsely prepared this application or related documents, I understand that it shall be considered an act of dishonesty, a possible DOT and or State Motor Carrier Regulations violation and subject me to immediate dismissal. I further agree, as a condition of employment, to correctly furnish additional information and complete such documents and examinations, inclusive of medical examinations, that the company from time to time may require. I also agree and understand that being allowed to make application for employment in no way obligates the company to employ me. I understand that if hired, I will be employed for a stated probationary period during which time I may be discharged without recourse. This certifies that I completed this application, and that all entries on it and information in it are true and correct to the best of my knowledge.
APPLICANT’S BACKGROUND INVESTIGATIVE AUTHORIZATION: I hereby authorize the company, or their agents, to investigate my complete background, regardless of subject, in order to ascertain that all information given by me is correct and further, I release any and all past employers, persons, organizations from all liability for any damages on account of furnishing any information and agree to indemnify and hold harmless all such persons and organizations who furnish any such information. (note: If there is anything in the statements you don’t understand, ask the person accepting your application for clarification and meaning.)
I am advised that I have the right to review, request correction or refute information that has been provided by a previous employer in response to inquiries regarding my safety history.
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.
Date
/ /
Duncan & Son Lines, Inc.
23860 W. Hwy. 85, Buckeye, AZ 85326
Phone: 623-386-4511, Toll Free: 800-528-4283, Fax: 623-386-8734
REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYERS
________________________________________________
states he was employed by your company
__ / __ / ____
__ / __ / ____ We appreciate your time and
courtesy in completing, in confidence, the information requested below.
__ / __ / ____
________________________________________________
APPLICANT’S AUTHORIZATION TO RELEASE INFORMATION
By my signature below, I authorize all previous employers to release all information requested below as required by FMCSR’s parts 382 through 391.
_________________________________________
_________ _________
______________________________________________________________________________
__________________________________________________________
DRIVING HISTORY (FMCSR’S 391.23)
Are the above dates of employment correct?
yes no.
Was the applicant employed as a Class A driver?
yes no.
Why did the applicant leave?
________________________________________________________________
If company policy allowed, would you rehire?
yes no.
_______________________
_______________________
Area of operation (states driven):
______ ______ ______
Injury or Fatality? yes no.
______
______
______
DOT DRUG & ALCOHOL TEST HISTORY (FMCSR’S 391.23, 382.201 THROUGH 391.23)
In the past three years, has this applicant:
- tested positive for a controlled substance? yes no.
- tested positive with alcohol concentration of .04 or greater? yes no.
- ever refused a required drug or alcohol test? yes no.
- ever violate any DOT drug or alcohol regulation? yes no.
- ever test positive for any employers prior to their employment with your company? yes no.
______________________________________________________
Signature __________________________________________________________
Date __ / __ / ____