| Candidate Information | | Title | Driver A | | Target Location | US-MO-Springfield |
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Click here or scroll down to respond to this candidatePlease send a copy of your CDL license with your application.DRIVERS APPLICATION FOR EMPLOYMENTT.T.I. Inc., P.O. Box Street Address
Dear Applicant: Per FMCSR 391.21 (d) Before an application is submitted, the motor carrier shall inform the applicant that the information he/she provides for the employment history may be used, and the applicants prior employers may be contacted, for the purpose of investigating the applicants safety performance history information. The prospective employer must also notify the driver in writing of his/her due process rights as specified in 391.2(i) regarding information received as a result of these inves- tigations. You the applicant have the following rights: (i) The right to review information provided by previous employers; (ii) 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; (iii) 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. Driver Applicant Driver ApplicantPrinted Name Signature Position(s) Applied for: Van Driver Flatbed Driver Stepdeck Driver Reefer Driver Name Social Security No. Last First MiddleAddress Street CityEmail Address Phone StateZipHow Long? Street City State & Zip CodeHow Long? Street City State & Zip CodeDid you have the legal right to work in the United States? Date of Birth / / Can you provide proof of age?(Required for Truck Drivers)In case of emergency, notify Name Address PhoneHave you worked for this company before? Where? Dates: From to Rate of Pay Position Reason for Leaving Are you now employed? If not, how long since leaving last employment? Who referred you? Rate of pay expected TRUCK DRIVER JOB DESCRIPTIONDriver is required to be knowledgeable and skilled in loading trailer, securing the load, and driving a semi-truck with trailer. Driver is responsible for performing pre-trip and post-trip vehicle inspections, keeping log on miles, filling out trip reports, etc. Filling fuel tanks, hook and unhook trailers, and performing preventative maintenance inspections. Are you capable of the above job description? Are you physically capable of lifting 50 pounds over your head? Are you physically capable of listing 50 pounds repetitively? Are you physically capable of sitting and driving for long periods of time? If applying for flatbed driver position, are you physically capable of pulling chain binder? If applying for van driver position, are you physically capable of shutting van trailer doors? Would you be willing to take a pre-placement physical examination? Would you be willing to take a pre-placement drug test? Do you have any pending convictions or charged against you? ADDRESSFOR PASTTHREEYEARS }Last EmployerName Phone Address Street City State ZipPosition Held Dates / / / / Type of Equip. Driven Areas Driven In Reason for Leaving Were you regulated by FMCSA during this job?YES NOWas this job a FMCSA safety sensitive function position sub- ject to DOT regulated controlled substance & alcohol testing?YES NODRIVERS APPLICATION FOR EMPLOYMENTEMPLOYMENT RECORD Complete all data for EACH last employer COMPLETELY. The U.S. Department of Transportation requires that the driver applicants show all employment for the past three years. Effective July 1, 1987, they must also show commercial driver employment for the seven years preceding this three year period. Sec. 291.21 (b) (10) 911). Account for any gaps in employment between employers.Second Last EmployerName Phone Address Street City State ZipPosition Held Dates / / / / Type of Equip. Driven Areas Driven In Reason for Leaving Were you regulated by FMCSA during this job?YES NOWas this job a FMCSA safety sensitive function position sub- ject to DOT regulated controlled substance & alcohol testing?YES NOThird Last EmployerName Phone Address Street City State ZipPosition Held Dates / / / / Type of Equip. Driven Areas Driven In Reason for Leaving Were you regulated by FMCSA during this job?YES NOWas this job a FMCSA safety sensitive function position sub- ject to DOT regulated controlled substance & alcohol testing?YES NOFourth Last EmployerName Phone Address Street City State ZipPosition Held Dates / / / / Type of Equip. Driven Areas Driven In Reason for Leaving Were you regulated by FMCSA during this job?YES NOWas this job a FMCSA safety sensitive function position sub- ject to DOT regulated controlled substance & alcohol testing?YES NOFifth Last EmployerName Phone Address Street City State ZipPosition Held Dates / / / / Type of Equip. Driven Areas Driven In Reason for Leaving Were you regulated by FMCSA during this job?YES NOWas this job a FMCSA safety sensitive function position sub- ject to DOT regulated controlled substance & alcohol testing?YES NOSixth Last EmployerName Phone Address Street City State ZipPosition Held Dates / / / / Type of Equip. Driven Areas Driven In Reason for Leaving Were you regulated by FMCSA during this job?YES NOWas this job a FMCSA safety sensitive function position sub- ject to DOT regulated controlled substance & alcohol testing?YES NOSeventh Last EmployerName Phone Address Street City State ZipPosition Held Dates / / / / Type of Equip. Driven Areas Driven In Reason for Leaving Were you regulated by FMCSA during this job?YES NOWas this job a FMCSA safety sensitive function position sub- ject to DOT regulated controlled substance & alcohol testing?YES NOEighth Last EmployerName Phone Address Street City State ZipPosition Held Dates / / / / Type of Equip. Driven Areas Driven In Reason for Leaving Were you regulated by FMCSA during this job?YES NOWas this job a FMCSA safety sensitive function position sub- ject to DOT regulated controlled substance & alcohol testing?YES NOACCIDENT RECORD OF PAST 10 YEARS OR MORE (Attach sheet if more space is needed.) DATES NATURE OF ACCIDENTS(HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES LAST ACCIDENT:NEXT PREVIOUS:NEXT PREVIOUS:NEXT PREVIOUS:NEXT PREVIOUS:TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 10 YEARS (Other than parking violations.) DATES NATURE OF ACCIDENTS(HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES LAST ACCIDENT:NEXT PREVIOUS:NEXT PREVIOUS:NEXT PREVIOUS:NEXT PREVIOUS:EDUCATIONCheck Highest Grade Completed: 1 2 3 4 5 6 7 8 High School: 1 2 3 4 College: 1 2 3 4 Last School Attended Name CityDid you graduate from Truck Driving School? No Yes Year Where EXPERIENCE AND QUALIFICATIONS DRIVERDRIVERLICENSESSTATE LICENSE NO. TYPE EXPIRATION DATEA. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO B. Has any license, permit or privilege ever been suspended or revoked? YES NO C. Have you ever been convicted of a felony? YES NO D. Have you ever been convicted of a DWI/OWI? YES NO E. 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 F. If the answer is yes, did you go to a substance abuse professional for an evaluation? YES NO IF YES TO ANY ANSWER ATTACH STATEMENT GIVING DETAILS! DRIVING EXPERIENCE FOR THE PAST TEN YEARSCLASS OF EQUIPMENT TYPE OF EQUIPMENT(VAN, TANK, FLAT, ETC.)DATESFROM TOAPPROX. NO. OF MILES(TOTAL)STRAIGHT TRUCKTRACTOR & SEMI-TRAILERTRACTOR - TWO TRAILERSOTHERList states operated in for last five years. Show special courses or training that will help you as a driver. Which safe driving award do you hold and from whom? List flatbed experience for the past 10 years. List van experience for the past 10 years. EXPERIENCE AND QUALIFICATIONS OTHERShow any trucking, transportation or other experience that may help in your work for this company. List courses and training other than shown elsewhere in this application. List special equipment or technical materials you can work with (other than those already shown). TO BE READ AND SIGNED BY APPLICANTThis 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 authorize you to make such investigations and inquiries of my personal employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools or persons from all liability in responding to inquiries in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company, as permitted by Law.DateApplicants SignaturePROCESS RECORDAPPLICANT HIRED REJECTED DATE EMPLOYED POINT EMPLOYED DEPARTMENT CLASSIFICATION(IF REJECTED, SUMMARY REPORT OR REASONS SHOULD BE PLACE IN FILE) THIS SECTION TO BE FILLED IN BY RESPONSIBLE OFFICER OR COMPANY REPRESENTATIVE 1. APPLICATION2. INTERVIEW3. PAST EMPLOYMENT4. WRITTEN EXAM5. ROAD TEST6. POLICE ANDTRAFFIC RECORDSignature or interviewing officer: SUPERIOR GOOD FAIR BELOW AVERAGE POOR WRITTEN RECORD ON FILE Please list each state which you held an operator's license or permit for the last three years T.T.I., Inc.P.O. Box 188Eden, WI 53019Ruth DudarenkeDriver Recruiter16-F (Rev. 7/9). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), I hereby certify the following: 1. The consumer (applicant) has authorized in writing the procurement of this report. 2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes;3. The information requested below will be used for a permissible purpose (i.e., information for employment purposes) and will be used for no other purpose;4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and 5. Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency. I also hereby certify that this report request and the above applicants release notice meet the definition of permissible uses of state motor vehicle records under the provisions of the Drivers Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Section 300002(a)).Signature of Requestor DateTO:DEAR SIR / MADAM:The following named person has made application with our company for the position of . In accordance with Section 391.23, Federal Department of Transportation Regulations, please furnish the undersigned with the applicants driving record for the past three years.The following named person is employed with our company in the position of . In accordance with Section 391.23, Federal Department of Transportation Regulations, please furnish the undersigned with the applicants driving record for the past three years. NAME OF APPLICANT/DRIVER ADDRESS Number & StreetCityStateZipFORMER ADDRESS Number & StreetCityStateZipDATE OF BIRTH - - SSN LICENSE NO. REQUESTED BYName of Company Typed NameAddress TitleCityState SignatureT.T.I., Inc.REQUEST FOR CHECK OF DRIVING RECORDI hereby authorize you to release the following information to Prospective Employerfor purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. Applicants Signature DateFAXDTO: ATTN: FAX:LOCAL 2ND SEAT STRAIGHT TRUCK LOWBOY MACHINERY GENERAL COMMODITIESSTUDENT BUS VAN REEFER HOUSEHOLD IRON, STEEL PRODUCTSOTHER OTHER LUMBER OTHER States Operated in: Was Applicant involved in any accidents with you? YES NO 3 Year Accident History: # Chargeable # Non-Chargeable DATE CITY/STATE # OF FATALITIES # OF INJURIES TOWYES NO $ YES NO $ YES NO $ Has driver had any hours of service violations that resulted in and out of service order? YES NO Did he/she have any problems with customers? YES NO Was he/she a safe and conscientious driver? YES NO Did he/she have any cargo claims? YES NO $ Was he/she considered cooperative & dependable? YES NO Were loading and unloading schedules made on time? YES NO Did he/she have a good safety attitude toward logs? YES NO Would you re-employ or re-qualify? YES NOWhat was his/her reason for leaving? Discharged Resignation Lay-off Military Other Comments: If driver was not subject to DOT test requirements while employed by this employer, please check here. Sign below and return.1. Has this person ever tested positive for controlled substances in the last three years? YES NO 2. Has this person ever had an alcohol test with a Breath Alcohol Concentration 0.04 or greater in the last three years? YES NO3. Has this person ever refused a required test for drugs or alcohol in the last three years(including adulterated or substituted drug test results)? YES NO 4. If this person has violated a DOT drub/alcohol regulation, do you have documentation of the employees successful completion of DOT return-to-duty requirement, including follow-up test? YES NO 5. Had driver ever failed to undertake or complete a rehabilitation program recommended by a professional? YES NO 6. Has this person violated any other DOT agency drug and alcohol testing regulations? YES NO(Please send this documentation, if applicable.)Completed by Title Date Company Address FROM: T.T.I., Inc.ATTN: Ruth DudarenkeFAX: PHONE NUMBER AVAILABLE or PHONE NUMBER AVAILABLEPHONE: PHONE NUMBER AVAILABLEREQUEST FOR INFORMATION FROM PREVIOUS EMPLOYERSECTION 1 (to be completed by driver)I, hereby authorize to release the following information to T.T.I., Inc. for the purpose of investigation as required by Section 391.23, 382.405, 40.25 and 382.413 of the FMCSA regulations. You are released from any and all liability, which may result from furnishing such information. I also realize I may not be offered a job based on information in this report. Date Social Security # - - DOB __ / __ / __ Applicants Signature 6(&7,21 WR EH FRPSOHWHG E\ SUHYLRXV HPSOR\HU 21 GULYHUV GR 127 ILOO RXW WKLV VHFWLRQ Applicants Name Employment Date(s): From To From To Type of work performed? If Driver, answer below:OTR 1ST SEAT TRACTOR/SEMI FLATBED Type of Commodities Hauled? DISCLOSURE AND AUTHORIZATION FORM TO OBTAIN CONSUMER REPORTS FOR DOT EMPLOYMENT PURPOSESPlease Read Carefully Before Signing the Authorization DISCLOSUREIn considering you for employment, T.T.I., Inc. may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from consumer reporting agencies, such as iiX and IntelliCorp Records, Inc. This information is being requested in compliance with DOT regulations 40.25 and FMCSA regulation 391.23. By signing the authorization form, I authorize the release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three (3) years: 1. Alcohol tests with a result of 0.04 or higher alcohol concentration; 2. Verified positive drug tests; 3. Refusals to be tested; 4. Other violations of DOT agency drug and alcohol testing regulations; 5. Documentations, if any, of completion of the return-to-duty process following a rule violation; 6. Information obtained from previous employers of a drug and alcohol rule violation. iiX, a unit of ISO Claim Services, Inc., can be contacted by mail at 1716 Briarcrest Drive, Suite 200; Bryan, TX 77802; or phone: PHONE NUMBER AVAILABLE; or website: www.iix.com. IntelliCorp Records, Inc. can be contacted by mail at 3000 Auburn Dr, Suite 410; Beachwood, OH 44122; or phone: 1-888-946-8355; or website: www.intellicorp.net. For explanation purposes: a consumer report is a written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. Such information may include, for example, credit information, criminal history reports, or driving records; and an investigative consumer report is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your current and/or prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information. In the event an investigative consumer report is requested about you, you are entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act (FCRA). Under the FCRA, before the Company can obtain a consumer report or investigative consumer report about you for employment purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.I have read and understand the foregoing Disclosure, and authorize T.T.I., Inc. to obtain and rely upon consumer reports or investigative consumer reports concerning me. By my signature below, I authorize the Company to obtain any such reports and to share the information received with any person involved in their decision about me. I do do not authorize you to contact my current employer for Employment and Reference Verifications.Additionally, I acknowledge receipt of the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, any related state summary of rights(collectively Summary of Rights).This consent will not affect my ability to question or dispute the accuracy of any information contained in a Report. I understand that if Company makes a conditional decision to disqualify me based all or in part on my Report, I will be provided with a copy of the Report and another copy of the Summary of Rights, and if I disagree with the accuracy of the purported disqualifying information in the Report, I must notify Company within five business days of my receipt of the Report that I am challenging the accuracy of such information with iiX and Intellicorp.(This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application.)I also agree that this Disclosure and Authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the Company.Printed NameApplicant Signature DateGeneral Consent for Full Query of theFederal Motor Carrier Safety Administration (FCSA) Drug and Alcohol ClearinghouseI am signing this consent form in connection with my employment or engagement to operate for, or application to become qualified as a commercial driver by TTI INC. (the Company). By signing below, I hereby provide consent to the Company to conduct a full query of the FMCSA Commercial Drivers License Drug and Alcohol Clearinghouse (the Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I acknowledge and understand that this consent extends to queries to be conducted as part of the Companys initial review of my qualifications to operate as mandated by the Federal Motor Carrier Safety Regulations.I understand that if the Full query conducted by the Company indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to the Company without first obtaining additional specific consent from me.Finally, I understand that the Company must prohibit me from performing safety- sensitive functions, including driving a commercial motor vehicle, as required by FMCSAs drug and alcohol program regulations if I: (a) refuse to provide this consent for the Company to conduct a limited query of the Clearinghouse; or (b) refuse to provide the above-described consent to the FMCSA to disclose to the Company any drug or alcohol violation information responsive to a query. Signature: Date: Name Printed: |
