DRIVER APPLICATION FOR EMPLOYMENT

DABCO TRANSPORTATION, INC.
102 Division Street
Little Egg Harbor, NJ 08087
EXPERIENCE & QUALIFICATIONS
DRIVER LICENSES STATE LICENSE NUMBER TYPE EXPIRATION DATE
DRIVING EXPERIENCE
CLASS OF EQUIPMENT TYPE OF EQUIPMENT
(VAN, TANK, FLAT, ECT)		 DATE APPROXIMATE NUMBER
OF TOTAL MILES
FROM TO

STRAIGHT TRUCK

TRACTOR & SEMI TRAILERS

TRACTOR W/2 TRAILERS

OTHER
ACCIDENT RECORD FOR PAST 3 YEARS
DATES NATURE OF ACCIDENT
(HEAD ON, READ-END, UPSET, ECT)		 FATALITIES INJURIES

LAST ACCIDENT

NEXT PREVIOUS
TRAFFIC CONVECTIONS AND FORFEITURES FOR THE PAST 3 YEARS(OTHER THEN PARKING VIOLATIONS)
LOCATION DATE CHARGE PENALTY
  • A.

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

  • B.

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

  • IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS HERE:

  • C. Have you ever tested positive or refused to be tested on any pre-employment drug or alcohol test at the time of applying for Safety Sensitive Transportation work covered by DOT agency drug or alcohol testing rules, but were never hired?

  • IF YES, YOU MUST SUPPLY COMPLETION OF RETURN TO DUTY PROCESS.

EMPLOYMENT RECORD
NOTE: DOT REQUIRES ALL EMPLOYERS FOR THE PREVIOUS 3 YEARS AND ALL CDL EMPLOYMENT
FOR AN ADDITIONAL 7 YEARS, (possible 10 years total previous employment to be shown)

  • 1. LAST/CURRENT EMPLOYER
Yes
No

Yes
No
  • 2. SECOND LAST EMPLOYER
Yes
No

Yes
No
  • 3. NEXT LAST EMPLOYER
Yes
No

Yes
No

TO BE READ AND SIGNED BY APPLICANT

This certifies that this applicahon was completed by me. and that all entries on it and information in it are true. accurate and complete to the best of my knowledge.


BACKGROUND INVESTIGATION DISCLOSURE

(In accordance with the provisions of section604 (b) (2) (A) of the Fair Credit Reporting Act, Public law 9l-508, as amended by the Consumer Reporting Act of 1996 (Title ll, Subtitle D, Chapter 1, of Public Law 104-208

TO BE READ AND SIGNED BY APPLICANT

I am aware that all previous employers for whom I have worked will be contacted for the purpose of investigation my safety performance history as required by Sections 982.413, 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations including: Accident history, Identification and employment verification; Violations of alcohol and controlled substance prohibitions and all information relating to any rehabilitation program prescribed by a Substance Abuse Professional (SAP)


PROSPECTIVE DRIVER DUE PROCESS RIGHTS

You (as a prospective employee) have the following due process rights regarding the investigative information that will be provided to this employer.

  • The right to review information provided by previous employers;
  • 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 statment attached to the alleged erroneous information, if the previous employer and you cannot agree on the accuracy of the information.

Note to prospective employee. lf you wish to review previous employer-provided investigative information, you must make a request, in writing, to this employer any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. If you choose to make this request, this prospective employer must provide this information within 5 business days of receiving the written request or within 5 business days of receiving the information from the previous employer. lf you do not arrange to pick up or receive the requested records within 30 days of this employer making the information available, you are considered to have waived your request the records. If you wish to request correction of erroneous information of records received from a previous employer, you must send the request for the correction to the previous employer that provided the records to this prospective employer.


Note: A Motor carrier may require an applicant to provide additional information to that which is required by the Federal Motor Carrier Safety Regulations.