Post by trucking07 on Jul 3, 2017 18:15:56 GMT -8
1
COMMERCIAL DRIVER APPLICATION
Company Socal Lowbed Services
Address 4750 Burr St
City Bakersfield State CA Zip 93308
APPLICANT INFORMATION
DATE 7-3-17 Position applying for: Driver
NAME. Willie Martin
PHONE (713)8396521 EMERGENCY PHONE ( )___________________
AGE 23
DATE OF BIRTH 01-09-1994 SS#XXX-XX-XXXX
(The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40
but less than 70 years of age.)
PHYSICAL EXAM EXPIRATION DATE 6-30-17
CURRENT & PREVIOUS THREE YEARS ADDRESSES:
___________________________________________________FROM________________TO____________________
___________________________________________________FROM________________TO____________________
___________________________________________________FROM________________TO____________________
HAVE YOU WORKED FOR THIS COMPANY BEFORE? _______Yes X No
If yes, give dates: From_______________ To_________________
Reason for leaving? _______________________________________________________________________________
EDUCATION HISTORY:
Please circle the highest grade completed:
Grade school: 1 2 3 4 5 6 7 8 9 10 11 12
College: 1 2 3 4 Post Graduate: 1 2 3 4
EMPLOYMENT HISTORY:
Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self
employment periods, and all commercial driving experience for the past ten (10) years.
Mo/Yr Mo/Yr Present or Last Employer
From 2003To 2017Name SCS Trucking Position Held DRIVER Address Prague, Czech Republic
Reason for leaving no Heavy Haul Devision
Were you subject to the FMCSRs while employed here? X Yes _____________No
Mo/Yr Mo/Yr Present or Last Employer
From SEPT 03 To PRESENT Name_____________________________________________________________
Position Held_____________________Address_________________________________________________________
Reason for leaving___________________________________________
Were you subject to the FMCSRs while employed here? ____________Yes _____________No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol
testing requirements of 49 CFR Part 40? _______________Yes _______________No
Mo/Yr Mo/Yr Present or Last Employer
From____________To___________ Name_____________________________________________________________
Position Held_____________________Address_________________________________________________________
Reason for leaving___________________________________________Company phone ( )__________________
Were you subject to the FMCSRs while employed here? ____________Yes _____________No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol
testing requirements of 49 CFR Part 40? _______________Yes _______________No
Mo/Yr Mo/Yr Present or Last Employer
From____________To___________ Name_____________________________________________________________
Position Held_____________________Address_________________________________________________________
Reason for leaving___________________________________________Company phone ( )__________________
Were you subject to the FMCSRs while employed here? ____________Yes _____________No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol
testing requirements of 49 CFR Part 40? _______________Yes _______________No
Mo/Yr Mo/Yr Present or Last Employer
From____________To___________ Name_____________________________________________________________
Position Held_____________________Address_________________________________________________________
Reason for leaving___________________________________________Company phone ( )__________________
Were you subject to the FMCSRs while employed here? ____________Yes _____________No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol
testing requirements of 49 CFR Part 40? _______________Yes _______________No
Mo/Yr Mo/Yr Present or Last Employer
From____________To___________ Name_____________________________________________________________
Position Held_____________________Address_________________________________________________________
Reason for leaving___________________________________________Company phone ( )__________________
Were you subject to the FMCSRs while employed here? ____________Yes _____________No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol
testing requirements of 49 CFR Part 40? _______________Yes _______________No
(Attach additional sheets for 10-year history, if needed.)
3
DRIVING EXPERIENCE
Class of Equipment From To Approximate Number of Miles
Straight Truck 105,000
Tractor & Semitrailer 3.5million
Tractor & two
Trailers 200,000
Tractor & triple
Trailers 200,000
Other
List states operated in, for the last five (5) years: TX CA FL MD NY SEA
List special courses/training completed (PTD/DDC, HAZMAT, ETC) HNTPD
List any Safe Driving Awards you hold and from whom: 1 Milion Mile award Jevic Transportation
Accident Record for past three (3) years: (attach sheet if more space is needed):
Date of Accident Nature of Accidents
Location of
Accident
# of
Fatalities # of People Injured
(Head on, rear end, etc)
Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):
Date Location Charge Penalty
Driver’s License (list each driver’s license held in the past three(3) years:
State License Type Endorsements Expiration Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle? ________Yes X No
Has any license, permit or privilege ever been suspended or revoked? ________Yes X No
Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in
the job description)? ________Yes X No
Have you ever been convicted of a felony? ________Yes X No
If the answers to any questions listed above are “yes”, give details__________________________________________
4
Job References
List three (3) persons for references, other than family members, who have knowledge of your safety habits.
Name________________________________Address_________________________________Phone_______________
Name________________________________Address_________________________________Phone_______________
Name________________________________Address_________________________________Phone_______________
To Be Read and Signed by Applicant:
It is agreed and understood that any misrepresentation given on this application shall be considered an act of
dishonesty.
It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain
any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases
employers and person named herein from all liability for any damages on account of his furnishing such information.
It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this
investigation may include an investigating Consumer Report, including information regarding my character, general
reputation, personal characteristics, and mode of living.
I agree to furnish such additional information and complete such examinations as may be required to complete my
application file.
It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.
It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be
disqualified without recourse.
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.
Applicant Signature :::WILLIE MARTIN Date 7-3-17
Remarks: (For office use only)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
COMMERCIAL DRIVER APPLICATION
Company Socal Lowbed Services
Address 4750 Burr St
City Bakersfield State CA Zip 93308
APPLICANT INFORMATION
DATE 7-3-17 Position applying for: Driver
NAME. Willie Martin
PHONE (713)8396521 EMERGENCY PHONE ( )___________________
AGE 23
DATE OF BIRTH 01-09-1994 SS#XXX-XX-XXXX
(The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40
but less than 70 years of age.)
PHYSICAL EXAM EXPIRATION DATE 6-30-17
CURRENT & PREVIOUS THREE YEARS ADDRESSES:
___________________________________________________FROM________________TO____________________
___________________________________________________FROM________________TO____________________
___________________________________________________FROM________________TO____________________
HAVE YOU WORKED FOR THIS COMPANY BEFORE? _______Yes X No
If yes, give dates: From_______________ To_________________
Reason for leaving? _______________________________________________________________________________
EDUCATION HISTORY:
Please circle the highest grade completed:
Grade school: 1 2 3 4 5 6 7 8 9 10 11 12
College: 1 2 3 4 Post Graduate: 1 2 3 4
EMPLOYMENT HISTORY:
Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self
employment periods, and all commercial driving experience for the past ten (10) years.
Mo/Yr Mo/Yr Present or Last Employer
From 2003To 2017Name SCS Trucking Position Held DRIVER Address Prague, Czech Republic
Reason for leaving no Heavy Haul Devision
Were you subject to the FMCSRs while employed here? X Yes _____________No
Mo/Yr Mo/Yr Present or Last Employer
From SEPT 03 To PRESENT Name_____________________________________________________________
Position Held_____________________Address_________________________________________________________
Reason for leaving___________________________________________
Were you subject to the FMCSRs while employed here? ____________Yes _____________No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol
testing requirements of 49 CFR Part 40? _______________Yes _______________No
Mo/Yr Mo/Yr Present or Last Employer
From____________To___________ Name_____________________________________________________________
Position Held_____________________Address_________________________________________________________
Reason for leaving___________________________________________Company phone ( )__________________
Were you subject to the FMCSRs while employed here? ____________Yes _____________No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol
testing requirements of 49 CFR Part 40? _______________Yes _______________No
Mo/Yr Mo/Yr Present or Last Employer
From____________To___________ Name_____________________________________________________________
Position Held_____________________Address_________________________________________________________
Reason for leaving___________________________________________Company phone ( )__________________
Were you subject to the FMCSRs while employed here? ____________Yes _____________No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol
testing requirements of 49 CFR Part 40? _______________Yes _______________No
Mo/Yr Mo/Yr Present or Last Employer
From____________To___________ Name_____________________________________________________________
Position Held_____________________Address_________________________________________________________
Reason for leaving___________________________________________Company phone ( )__________________
Were you subject to the FMCSRs while employed here? ____________Yes _____________No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol
testing requirements of 49 CFR Part 40? _______________Yes _______________No
Mo/Yr Mo/Yr Present or Last Employer
From____________To___________ Name_____________________________________________________________
Position Held_____________________Address_________________________________________________________
Reason for leaving___________________________________________Company phone ( )__________________
Were you subject to the FMCSRs while employed here? ____________Yes _____________No
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol
testing requirements of 49 CFR Part 40? _______________Yes _______________No
(Attach additional sheets for 10-year history, if needed.)
3
DRIVING EXPERIENCE
Class of Equipment From To Approximate Number of Miles
Straight Truck 105,000
Tractor & Semitrailer 3.5million
Tractor & two
Trailers 200,000
Tractor & triple
Trailers 200,000
Other
List states operated in, for the last five (5) years: TX CA FL MD NY SEA
List special courses/training completed (PTD/DDC, HAZMAT, ETC) HNTPD
List any Safe Driving Awards you hold and from whom: 1 Milion Mile award Jevic Transportation
Accident Record for past three (3) years: (attach sheet if more space is needed):
Date of Accident Nature of Accidents
Location of
Accident
# of
Fatalities # of People Injured
(Head on, rear end, etc)
Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):
Date Location Charge Penalty
Driver’s License (list each driver’s license held in the past three(3) years:
State License Type Endorsements Expiration Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle? ________Yes X No
Has any license, permit or privilege ever been suspended or revoked? ________Yes X No
Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in
the job description)? ________Yes X No
Have you ever been convicted of a felony? ________Yes X No
If the answers to any questions listed above are “yes”, give details__________________________________________
4
Job References
List three (3) persons for references, other than family members, who have knowledge of your safety habits.
Name________________________________Address_________________________________Phone_______________
Name________________________________Address_________________________________Phone_______________
Name________________________________Address_________________________________Phone_______________
To Be Read and Signed by Applicant:
It is agreed and understood that any misrepresentation given on this application shall be considered an act of
dishonesty.
It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain
any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases
employers and person named herein from all liability for any damages on account of his furnishing such information.
It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this
investigation may include an investigating Consumer Report, including information regarding my character, general
reputation, personal characteristics, and mode of living.
I agree to furnish such additional information and complete such examinations as may be required to complete my
application file.
It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.
It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be
disqualified without recourse.
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.
Applicant Signature :::WILLIE MARTIN Date 7-3-17
Remarks: (For office use only)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________