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Driver Qualification Application
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DRIVER QUALIFICATION APPLICATION
Complete all required sections. Electronically sign and date, and then click “Submit”.
PERSONAL INFORMATION
*First Name
Middle Name
*Last Name
*Date of Birth
*Social Security Number
*Phone
*Phone Type
Home Phone
Cell Phone
*Email
*Present Address
*City
*State
*Zip Code
*How long have you lived there?
PREVIOUS THREE YEARS RESIDENCY
List any addresses you have maintained during the past three years other than your present address:
Past Address 1
City
State
Zip Code
How long?
Past Address 2
City
State
Zip Code
How long?
EMERGENCY CONTACT
*Contact Name
*Relationship
*Address
*Phone
OTHER INFORMATION
*Are you authorized to work in the United States?
Yes
No
If you are a resident alien, please give your alien number from your Resident Alien Card, Form I-1551:
*Have you ever interviewed for a job with Harrisburg Dairies, Inc.?
Yes
No
If yes, when?
*Have you ever been employed by Harrisburg Dairies, Inc?
Yes
No
If yes, when and what position?
*Are any relatives or friends currently employed at Harrisburg Dairies, Inc.?
Yes
No
Name of employee(s) & Department where employed:
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REFERENCES
List three business / work references who are NOT related to you and are NOT previous supervisors. If not applicable, list three school or personal references who are not related to you.
Reference 1
*Reference Name
*Reference Phone
*Reference Occupation
*Years known
Reference 2
*Reference Name
*Reference Phone
*Reference Occupation
*Years known
Reference 3
*Reference Name
*Reference Phone
*Reference Occupation
*Years known
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DRIVING RECORD
A - *Have you ever been denied a license or privilege to operate a motor vehicle?
Yes
No
If you answer "YES," please provide details.
B - *Has your motor vehicle operator's license, permit, or privilege ever been suspended or revoked?
Yes
No
If you answer "YES," when and for how long?
C - *Have you ever been disqualified from driving a motor vehicle under the D.O.T regulations?
Yes
No
If you answer "YES," when and for how long?
D - *Have you ever been convicted for driving under the influence of alcohol or drugs?
Yes
No
If you answer "YES," please provide details.
E - *Have you ever been convicted of possession, sale, or use of alcohol or narcotic drugs?
Yes
No
If you answer "YES," please provide details.
F - *Have you ever been convicted of a serious traffic violation, such as careless or reckless driving or willful reckless driving, etc.?
Yes
No
If you answer "YES," please provide details.
G - Have you, within the two years preceding the date of this application:
*Undergone an alcohol test in which a concentration of 0.04 or greater has been indicated?
Yes
No
If you answer "YES," please provide details.
*Undergone a controlled substance test in which a positive result has been verified?
Yes
No
If you answer "YES," please provide details.
*Refused to undergo either an alcohol or controlled substance test?
Yes
No
If you answer "YES," please provide details.
H - *Have you ever been convicted of a criminal felony?
Yes
No
If you answer "YES," please provide details.
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EMPLOYMENT HISTORY
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record). Begin with your present or most recent job and work backward in order, including all full and part-time employment. (Must list the complete mailing address: street number and name, city, state and zip code) All time must be accounted for, including military service, self employment, and periods of unemployment.
1 - Present/Most Recent Employer
*Present/Most Recent Employer
*Phone Number
Fax Number
*Address
*City
*State
*Zip Code
*Position Held
*Type of Equipment Driven:
*Areas in which you drove:
*Reason for leaving or why you are considering leaving?
*Dates Employed
*Starting Hourly Rate/Salary
*Final Hourly Rate/Salary
*Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Yes
No
*Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
2 - Previous Employer
Employer
Phone Number
Fax Number
Address
City
State
Zip Code
Position Held
Type of Equipment Driven:
Areas in which you drove:
Reason for leaving or why you are considering leaving?
Dates Employed
Starting Hourly Rate/Salary
Final Hourly Rate/Salary
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
3 - Previous Employer
Present/Most Recent Employer
Phone Number
Fax Number
Address
City
State
Zip Code
Position Held
Type of Equipment Driven:
Areas in which you drove:
Reason for leaving or why you are considering leaving?
Dates Employed
Starting Hourly Rate/Salary
Final Hourly Rate/Salary
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
4 - Previous Employer
Present/Most Recent Employer
Phone Number
Fax Number
Address
City
State
Zip Code
Position Held
Type of Equipment Driven:
Areas in which you drove:
Reason for leaving or why you are considering leaving?
Dates Employed
Starting Hourly Rate/Salary
Final Hourly Rate/Salary
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
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QUALIFICATIONS
Education & Training
*Driver Training Course or Driving School Attended
*Date Completed:
Driver Training Course or Driving School Attended
Date Completed:
Driver Training Course or Driving School Attended
Date Completed:
Driver’s License
List All Driver’s Licenses Held in the Past Five Years
Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.
Current Drivers License
*Issuing State
*License No.
*Class
*Endorsements
*Expiration Date
*Valid
Yes
No
Previous Drivers License 1
Issuing State
License No.
Class
Endorsements
Expiration Date
Valid
Yes
No
Previous Drivers License 2
Issuing State
License No.
Class
Endorsements
Expiration Date
Valid
Yes
No
Previous Drivers License 3
Issuing State
License No.
Class
Endorsements
Expiration Date
Valid
Yes
No
Traffic Convictions and Forfeitures
Have You Had Any Traffic Convictions or Forfeitures?
Yes
No
If yes, list all convictions for the past five years, including personal vehicle (other than parking violations).
Incident 1
Date
City & State
Charge / Violation
Type of Vehicle
Penalty
Incident 2
Date
City & State
Charge / Violation
Type of Vehicle
Penalty
Incident 3
Date
City & State
Charge / Violation
Type of Vehicle
Penalty
Incident 4
Date
City & State
Charge / Violation
Type of Vehicle
Penalty
Accident Record
Have You Had Any Accidents?
Yes
No
If yes, list all involvement with truck and car, including property damage, for the past five years, including preventable and non-preventable.
Accident 1
Date
City & State
Type of Vehicle
Nature of Accident
No. of Fatalities
No. of Injuries
Employer
Amount of Property Damage
Accident 2
Date
City & State
Type of Vehicle
Nature of Accident
No. of Fatalities
No. of Injuries
Employer
Amount of Property Damage
Accident 3
Date
City & State
Type of Vehicle
Nature of Accident
No. of Fatalities
No. of Injuries
Employer
Amount of Property Damage
Accident 4
Date
City & State
Type of Vehicle
Nature of Accident
No. of Fatalities
No. of Injuries
Employer
Amount of Property Damage
General Driving Experience
Describe the Nature and Extent of Your Experience in the Operation of Commercial Vehicles
Tractor Semi-Trailer
Total Experience (Wks., Mos., Yrs.)
Approximate Mileage
Types of Commodoties Transported
States of Operation
Double/Triple Trailers
Total Experience (Wks., Mos., Yrs.)
Approximate Mileage
Types of Commodoties Transported
States of Operation
Straight Truck
Total Experience (Wks., Mos., Yrs.)
Approximate Mileage
Types of Commodoties Transported
States of Operation
Passenger Bus
Total Experience (Wks., Mos., Yrs.)
Approximate Mileage
Types of Commodoties Transported
States of Operation
Other Vehicle:
Total Experience (Wks., Mos., Yrs.)
Approximate Mileage
Types of Commodoties Transported
States of Operation
The date of my last accident while driving a commercial vehicle was:
Since that time, I have driven approximately # accident free miles.
Physical Condition
*Do you have a current D.O.T. physical certificate?
Yes
No
If yes, please provide the following:
Name of Doctor:
Address:
Exam Date:
Expiration Date:
*Are you physically capable of heavy manual labor (able to lift/push/pull approx. 75 pounds) that may be required in the loading and unloading of cargo, with or without a reasonable accomodation?
Yes
No
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Applicant Statement
I understand that any false or misleading statements in this application will be sufficient cause for rejection of my application if the Company has not already qualified me as a driver and for immediate disqualification if it has qualified me as a driver.
I agree that Harrisburg Dairies, Inc. is not obligated to employ me. I further agree that if I am employed as a Driver, I have the right to terminate my employment at any time for any reason, and that Harrisburg Dairies, Inc. has the same right. Any false, misleading or incomplete statement of the information requested in this application will be sufficient grounds for discharge from employment as a Driver.
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.
I agree to furnish such additional information and complete such examinations as may be required to complete my driver qualification file.
I HEREBY ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND AGREE WITH THE PRECEEDING STATEMENTS.
*Applicant's Name
*Social Security Number
*Signature of Applicant
*Today's Date
Applicant Statement
I hereby authorize my prior employers to provide Harrisburg Dairies, Inc. with all information regarding my performance, character and conduct while in their employ, and I hereby release my prior employers from any liability for providing such information.
Alcohol and Controlled Substance Testing
In compliance with the requirements of 49 C.F.R. S382.413, I hereby authorize HARRISBURG DAIRIES, INC. to obtain from my prior employers the information on me which they are required to maintain by 49 C.F.R. S382.401 (b)(1)(i) through (iii) regarding alcohol tests with a concentration result of 0.04 or greater, positive controlled substance test results, and refusals to be tested during the 3 years preceding the date of this application. I hereby authorize and consent to the release of such information by my prior employers to HARRISBURG DAIRIES, INC. in personal interviews, telephone interviews, letters, or any other method insuring confidentiality. I hereby authorize HARRISBURG DAIRIES, INC. to release such information to any employee of whose duties require them to assess this application or to make any recommendations or decisions with respect to it.
Consumer Reports
I hereby authorize HARRISBURG DAIRIES, INC. to obtain one or more consumer reports containing information regarding my employment history, driving record, and arrest/conviction in connection with this application and, if I am hired or qualified, to obtain additional consumer reports in connection with continuation of my employment or qualification.
*Signature of Applicant
*Today's Date
IMPORTANT: THIS APPLICATION MUST BE SIGNED AND DATED BY APPLICANT IN TWO PLACES.
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