APPLICATION FOR QUALIFICATION
APP1
     
Full Name:
 
Email:
 
Phone Number:
Secondary Phone Number:
Emergency Person:
Emergency Phone Number:
Age:
Date Of Birth:
age discrimination act
Social Security Number:
Physical Exam Expiration Date:
Current and 3 years previous addresses:
  
From:
To:
From:
To:
From:
To:
     
 
Have you worked for this company before?
 
 
If Yes - give dates:
 From: To:
 
Reason for leaving?:
       
Education History
Highest Grade Completed:
  
       
Employment History
app2
Present or Last Employer
From: Employer Name:
Position Held: Address:
Reason For Leaving: Phone:
Were you subject to the FMCSRS* while working here?  

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug alcohol testing requirements of 49CFR Part 40?
Previous Employer
From: Employer Name:
Position Held: Address:
Reason For Leaving: Phone:
Were you subject to the FMCSRS* while working here?  

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug alcohol testing requirements of 49CFR Part 40?
Previous Employer
From: Employer Name:
Position Held: Address:
Reason For Leaving: Phone:
Were you subject to the FMCSRS* while working here?  

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug alcohol testing requirements of 49CFR Part 40?
Previous Employer
From: Employer Name:
Position Held: Address:
Reason For Leaving: Phone:
Were you subject to the FMCSRS* while working here?  

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug alcohol testing requirements of 49CFR Part 40?
Previous Employer
From: Employer Name:
Position Held: Address:
Reason For Leaving: Phone:
Were you subject to the FMCSRS* while working here?  

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug alcohol testing requirements of 49CFR Part 40?
app3
Driving Experience
Class of Equipment: From:
Type of Vehicle Driven: Approximate # of miles:
Class of Equipment: From:
Type of Vehicle Driven: Approximate # of miles:
Class of Equipment: From:
Type of Vehicle Driven: Approximate # of miles:
Class of Equipment: From:
Type of Vehicle Driven: Approximate # of miles:
List states operated in for the past 5 years:
List any Safe driving Awards you hold and from whom:

Accident record for past three years:
Date of Accident:
Nature of Accident (Head-on, Collision, Upset, Etc.):
Location of Accident:
# of Fatalities or Injuries:
Date of Accident:
Nature of Accident (Head-on, Collision, Upset, Etc.):
Location of Accident:
# of Fatalities or Injuries:
Date of Accident:
Nature of Accident (Head-on, Collision, Upset, Etc.):
Location of Accident:
# of Fatalities or Injuries:

Traffic Convictions and forfeitures for past 3 years (other than parking tickets):
Date: Location:
Charge: Penalty:
Type of vehicle:
Date: Location:
Charge: Penalty:
Type of vehicle:
Date: Location:
Charge: Penalty:
Type of vehicle:

Drivers License (List every license held in the past three years):
State: Lic #: Type:
Expiration Date: Endorsements:
State: Lic #: Type:
Expiration Date: Endorsements:
State: Lic #: Type:
Expiration Date: Endorsements:
       
Do you have a TWIC card?: If Yes - what is your TWIC Number?:
Do you have a valid passport?
Have you ever been denied a license, permit or privilage to operate a motor vehicle?:
Has any license, permit or privilage ever been suspended or revoked?:
Is there any reason you might be unable to perform the functions of the job for which you've performed?:
Have you ever been convicted of a felony?:
If you answered any of the above 4 questions "Yes" - please provide details:
Have you ever tested positive for the use of drugs or alcohol while being an applicant or actually employed by a motor carrier?:
If Yes (to above question) please explain:
 
Personal References
Please list three persons for references, other than family members, who have knowledge of your safety habits:
Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:
       
Driver's Rights Pertaining To Release Of Driver
Information Under Regulation 391.23
       
Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.
• (a)(1) An inquiry into the driver's driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator's license or permit during those three years; and
• (a)(2) An investigation of the driver's employment record during the preceding three years.
• (b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver's employment begins and be retained in compliance with 391.51.
• (c) Replies to the investigations of the driver's safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver's employment begins. This goes into effect after October 29, 2004.
• (d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.
• (e) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.
Drivers have the following rights:
1. The right to review information provided by previous employers.
2. 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.
3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.
Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver's request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the Driver's Safety Performance History.
       
I acknowledge that I have read and understand the contents of this document.
Date: Initials:
Name:
       
Important Notice
Regarding Background Reports From The PSP Online Service
       
In connection with your application for employment with Keane Thummel Trucking, Inc. (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).
When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.
When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.
Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.
Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co- driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
AUTHORIZATION
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Keane Thummel Trucking, Inc. (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.
I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data.
I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.
I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Date: Initials:
Name:
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.
       
Driver Applicant Drug And Alcohol
Pre-Employment Statement
       
CFR Part 40.25(j) requires the employer to ask any applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, we must not use the employee to perform safety-sensitive functions, until and unless the potential employee provides documentation of successful completion of the return-to-duty process. (See Section 40.25(b)(5) and (e).
As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part 40.25(j) to respond to the following questions.
1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?
Yes No
2. Have you ever tested positive, refused, tampered or adulterated any DOT required drug or alcohol test required by the Federal DOT to perform safety sensitive functions?
Yes No
3. Have you ever violated any drug or alcohol Federal DOT Regulations?
Yes No
4. If you answered yes, to the above question, can you provide proof that you have successfully completed the DOT return-to-duty requirements?
Yes No
       
My initials certifies that the information provided is true and correct.
Date: Initials:
Name:

I agree that the above information is true and correct, by clicking submit I agree to the terms as indicated above.
By clicking submit, I authorize this as my electronic signature.