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Click here or scroll down to respond to this candidateSTICandidate's Name
Street Address Wilcox StreetChesapeake, Virginia Street Address
Phone PHONE NUMBER AVAILABLE Fax PHONE NUMBER AVAILABLEEmployee ApplicationRead this cover letter before you complete the application. Make sure you fill out all parts of the application. You must provide at least 10 years of employment history in accordance with the Federal Highway Administration. DO NOT leave any gaps in your employment. If you were not employed for any period of time, you must provide a reason for the UNEMPLOYMENT.Any application that is not completely filled out will not be considered for employment. A written description must be provided for any accident(s) you have on your driving record. You may be required to provide an accident report for each accident. Service Transfer, Inc. is an equal employment opportunity employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status or non-job related disabilities.Once your application has been approved you will be required to take and pass a pre-employment drug test.Thank you for your interest in employment with SERVICE TRANSFER, INC. Applicants Name: Date: / / REMOVE AND RETAIN PAGE 12 FOR YOUR RECORDSRevised 08151 of 12SERVICE TRANSFER, INC.CHARLESTON TERMINAL4361 Headquarters RoadN. Charleston, South Carolina 29405Phone PHONE NUMBER AVAILABLE Fax PHONE NUMBER AVAILABLECHARLOTTE TERMINAL4201 Northpointe Industrial BoulevardCharlotte, North Carolina 28216Phone PHONE NUMBER AVAILABLE Fax PHONE NUMBER AVAILABLEWILMINGTON TERMINAL3701 River RoadWilmington, North Carolina 28412Phone PHONE NUMBER AVAILABLE Fax PHONE NUMBER AVAILABLEGREENSBORO TERMINAL3231 Pinecroft CourtGreensboro, North Carolina 27407Phone PHONE NUMBER AVAILABLE Fax PHONE NUMBER AVAILABLESTIApplication for EmploymentDate of Application:Terminal Location: Chesapeake VA Wilmington NC Charleston SC Charlotte NC Greensboro NC Local OR Regional OR OTRIn compliance with Federal and State Equal Employment Opportunity Laws, qualified applicants are considered for all positions without regard to race, color, religion, sex national origin, age, marital status, veteran status, non-job related disability, or any other protected group.Applicants Name Social Security # Last First MIList your addresses of residency for the past 3 years. 391.21(b) (2)&(3) Current Address How Long? Street City State Zip yr./mo.How Long? Street City State Zip yr./mo.How Long? Street City State Zip yr./mo.How Long? Street City State Zip yr./mo.Home Phone# Cell# Date of Birth / / Present Age(Required for Commercial Drivers)Drivers License# Issuing State Type Expiration Date / / TWIC Card # Expiration Date / / Do you have the legal right to work in the United States? Yes No if yes can you provide proof? Yes No Are you HAZMAT certified? Yes No Have you been trained in the handling procedures of Hazardous Material? Yes No Have you ever worked for this company before? Yes No Where? Dates: From To Reason for Leaving Do you posses a valid U. S. Department of Transportation physical examination long form? Yes No Date Issued: Have you ever been convicted of a felony? Yes NoIf yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment; all circumstances will be considered.Is there any reason you might be unable to perform the functions of the job you are applying for? Yes No If yes to previous question, please explain.2 of 12PreviousAddressesSERVICE TRANSFER, INC.Employment HistoryAll driver applicants who wish to drive a commercial vehicle in the act of interstate commerce MUST provide the following information on ALL employers during the preceding three (3) years. List complete mailing address, street number, city, state and zip code. 391.21(b)(10) In addition, all driver applicants must provide the following information on all employers for which the applicant drove a commercial motor* vehicle in the act of interstate commerce during the additional preceding seven (7) years. 391.21(b)(11)**LEAVE NO BREAKS IN EMPLOYMENT**(Note: List employers in reverse order starting with the most recent.) Employers Name From ToAddress Circle All That ApplyVan, Tank, Flat, Dump, Reefer, ContainerCity State Zip Code Position HeldContact Person Salary/wageReason for Leaving Phone #Were you subject to Federal Motor Carrier Safety Regulations while employed? 391.21(b)(10)(iv )(A) Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part40? 391.21(b)(10)(iv)(B) Yes No Employers Name From ToAddress Circle All That ApplyVan, Tank, Flat, Dump, Reefer, ContainerCity State Zip Code Position HeldContact Person Salary/wageReason for Leaving Phone #Were you subject to Federal Motor Carrier Safety Regulations while employed? 391.21(b)(10)(iv )(A) Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part40? 391.21(b)(10)(iv)(B) Yes No Employers Name From ToAddress Circle All That ApplyVan, Tank, Flat, Dump, Reefer, ContainerCity State Zip Code Position HeldContact Person Salary/wageReason for Leaving Phone #Were you subject to Federal Motor Carrier Safety Regulations while employed? 391.21(b)(10)(iv )(A) Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part40? 391.21(b)(10)(iv)(B) Yes No Employers Name From ToAddress Circle All That ApplyVan, Tank, Flat, Dump, Reefer, ContainerCity State Zip Code Position HeldContact Person Salary/wageReason for Leaving Phone #Were you subject to Federal Motor Carrier Safety Regulations while employed? 391.21(b)(10)(iv )(A) Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part40? 391.21(b)(10)(iv)(B) Yes No*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.3 of 12Accident Record for the past 5 years: (Attach sheet if more space is needed) If none write NONE 391.21(b)(7) DATES NATURE OF ACCIDENT(HEAD ON, REAR END, UPSET, ETC.)FATALITIES INJURIESLAST ACCIDENTNEXT PREVIOUSNEXT PREVIOUSTraffic Convictions & License Forfeiture for the past 3 years: (Other than parking violations) If none write NONE 391.21(b)(8)Location Date Charges Penalty(Attach sheet if more space is needed)1. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No 2. Has any license, permit, or privilege ever been suspended or revoked? Yes No 3. Have you ever been refused auto liability insurance? Yes No If you answered Yes to any of these questions please provide details: 391.21(b)(9) EducationCircle highest grade completed: PHONE NUMBER AVAILABLE 12 College: 1 2 3 4 Last school attended: Name City StType of Vehicles Operated & Type of Operation: 391.21(b)(6) Class of Equipment Circle Type of EquipmentDates Approx. # of MilesFrom (M/Y) To (M/Y) (Total)Straight Truck Yes NoVan, Tank, Flat, Dump,Reefer, ContainerTractor: Semi-Trailer Yes NoVan, Tank, Flat, Dump,Reefer, ContainerTractor: Two Trailers Yes NoVan, Tank, Flat, Dump,Reefer, ContainerList the states in which you have operated for the past five (5) years List area by state in which you are willing to operate 1. Have you ever tested positive or refused any pre-employment drug/alcohol test? Yes No 2. Have you ever been charged with driving under the influence of alcohol or other controlled substance? Yes No 3. Have you ever been convicted of possession, sale, or use of a controlled substance? Yes No If you answered Yes to any of these questions please provide details: 391.21(b)(9) 4 of 12List any trucking, transportation, or other experience that you would like the company to know about while considering your application. List any courses and/or training not shown elsewhere in this application that you would like the company to consider. TO BE READ AND SIGNED BY THE APPLICANT391.21(b)(12)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 hereby authorize Service Transfer, Inc. to make such investigations and inquiries of my personal, employment, financial, and/or medical history and other related matters as may be necessary in arriving at an employment decision. (Note: inquiries involving medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health car providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.I understand that information that I provide regarding current and/or previous employers may be used for the purpose of investigating my safety performance history as required by Section 391.23(d) and (e) of the Federal Motor Carrier Safety Regulations. I understand that I have the right to:Review information provided by previous employersHave errors in the information corrected by previous employers and for those previous employers to resend the corrected information to the prospective employer; andHave a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the informationIn the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I further understand that I will be on a probationary period of 60 days and may be released from work during that period without explanation. I also understand that in accordance with the Federal Motor Carrier Safety Regulations, Section 391.103, I am required to submit to urinalysis testing upon acceptance of employment. A positive test for controlled substances and/or alcohol will medically disqualify me from the operation of a commercial motor vehicle and my employment with this company will be terminated immediately.Applicants Signature Date Completed5 of 12Employment History (Continued)Employers Name From ToAddress Circle All That ApplyVan, Tank, Flat, Dump, Refer, ContainerCity State Zip Code Position HeldContact Person Salary/wageReason for Leaving Phone #Were you subject to Federal Motor Carrier Safety Regulations while employed? 391.21(b)(10)(iv )(A) Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part40? 391.21(b)(10)(iv)(B) Yes No Employers Name From ToAddress Circle All That ApplyVan, Tank, Flat, Dump, Reefer, ContainerCity State Zip Code Position HeldContact Person Salary/wageReason for Leaving Phone #Were you subject to Federal Motor Carrier Safety Regulations while employed? 391.21(b)(10)(iv )(A) Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part40? 391.21(b)(10)(iv)(B) Yes No Employers Name From ToAddress Circle All That ApplyVan, Tank, Flat, Dump, Reefer, ContainerCity State Zip Code Position HeldContact Person Salary/wageReason for Leaving Phone #Were you subject to Federal Motor Carrier Safety Regulations while employed? 391.21(b)(10)(iv )(A) Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part40? 391.21(b)(10)(iv)(B) Yes No Employers Name From ToAddress Circle All That ApplyVan, Tank, Flat, Dump, Reefer, ContainerCity State Zip Code Position HeldContact Person Salary/wageReason for Leaving Phone #Were you subject to Federal Motor Carrier Safety Regulations while employed? 391.21(b)(10)(iv )(A) Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part40? 391.21(b)(10)(iv)(B) Yes No Employers Name From ToAddress Circle All That ApplyVan, Tank, Flat, Dump, Reefer, ContainerCity State Zip Code Position HeldContact Person Salary/wageReason for Leaving Phone #Were you subject to Federal Motor Carrier Safety Regulations while employed? 391.21(b)(10)(iv )(A) Yes No Was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part40? 391.21(b)(10)(iv)(B) Yes No*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.6 of 12STIAPPLICANT: COMPLETE THIS BOX ONLYPrevious Employment & Drug/Alcohol CheckName: SSN: Dates From: Dates To: Eligible for Rehire: YES NO Upon Review Contact Information Individual Completing this form Company:Signature of Individual Completing this formAddress:City: St: Zip: Print Name / Title DateDid the applicant have any accidents while in your employ? No Yes If Yes, please explain 7 of 12SERVICE TRANSFER, INC.I hereby authorize you to release the following information to Service Transfer, Inc. for the purposes of investigation as required by sections 391.23 and drug and alcohol testing results as required by section 40.25 & 382.405 (f) and (h) of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information. Date Applicants SignatureService Transfer, Inc.4101 Wilcox StreetChesapeake, Virginia 23324Phone PHONE NUMBER AVAILABLE Fax PHONE NUMBER AVAILABLEType of WorkCompany DriverOwner OperatorLease PurchaseDrove for O/OOtherVehicle DrivenTractor TrailerSleeper CabDay CabStraight TruckOtherTrailer PulledDry Van 53TankersFlatbedReeferOtherAreas Run48 StatesRegionalLocalShuttleOtherCommoditiesGeneralBulkHazardousRefrigeratedOtherDatePreventableYesNoYesNo5YesNoDescriptionCostReason for LeavingResigned With NoticeResigned Without NoticeTerminated/DisqualifiedLaid OffWork RecordSatisfactoryUnauthorized PassengerFalsified Employment ApplicationNo ShowUnauthorized Use of FundsEquipment / Cargo LossQuit Under DispatchUnsatisfactory Safety RecordExcessive ComplaintsAbandonmentUnauthorized Equipment UseLate Pickup / DeliveryBased on the review of your companys drug and alcohol test record: 1. Has this individual had an alcohol test with a confirmed breath alcohol concentration of .04 or greater in the past three (3) years? YesNo2. Has this individual has a controlled substance test with a positive result in the past three (3) years? YesNo3. Has this individual refused (includes a verified adulterated or submitted results) a controlled substance test and/or alcohol test within the past three (3) years?YesNo4. Has this individual violated other DOT drug/alcohol regulations? YesNo5. Have you received information from a previous employer that this individual violated DOT drug and alcohol regulations? YesNo6. Has this individual undertaken or completed a rehabilitation program recommended by a SAT (substance abuse professional) under 382.605? YesNo1st REQUEST -2nd REQUEST -3rd REQUEST -STIDISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES DisclosureService Transfer, Inc. may request from a consumer reporting agency and for employment-related purposes, a consumer report(s) (commonly known as background reports) containing background information about you in connection with your employment or application for employment(including independent contractor or volunteer assignments, as applicable). HireRight, Inc. (HireRight) will prepare or assemble the background reports for Service Transfer, Inc.. HireRight is located and can be contacted at 3349 Michelson Drive, Suite 150, Irvine, CA 92612, (800) 400-2761, www.hireright.com. The background report(s) may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. They types of background information that may be obtained include, but are not limited to: criminal history; litigation history; motor vehicle record and accident history; social security number verification, address and alias history; credit history; verification of your education, employment and earnings history; professional licensing, credential and certification checks; drug/alcohol testing results and history; military service; and other information.AuthorizationI hereby authorize Service Transfer, Inc. to obtain the consumer reports described above about me. Applicant Name Applicant Signature OTHER DISCLOSURES, ACKNOWLEDGMENTS & AUTHORIZATIONS REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSESInvestigative Consumer Report: Service Transfer may request an investigative consumer report about you from HireRight, Inc. (HireRight), a consumer reporting agency, in connection with your employment or application for employment (including independent contractor or volunteer assignments, as applicable). An investigative consumer report is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews), the most common form of which is checking personal or professional references through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting Service Transfer, Inc. Ongoing Authorization: If Service Transfer, Inc. hires you or contracts for your services, Service Transfer, Inc. may obtain additional consumer reports and investigative consumer reports about you without asking for your authorization again, throughout your employment or your contract period, as allowed by law.Additional State Law Notices: Please see the Additional State Law Notices for California, Massachusetts, Minnesota, New Jersey, New York, and Washington that are provided below, as applicable. A California disclosure and summary of your rights under California Civil Code Section 1786.22, and a copy of New York Article 23-A, are being provided to you separately. Summary of Rights under the Fair Credit Reporting Act: A summary of your rights under the Fair Credit Reporting Act is being provided to you separately.San Francisco Fair Chance Ordinance Official Notice: A copy of the San Francisco Fair Chance Ordinance Official Notice is being provided to you separately. HireRight Privacy Policy: Information about HireRights privacy practices is available at www.hireright.com/Privacy-Policy.aspx.8 of 12SERVICE TRANSFER, INC.ACKNOWLEDGMENTS & AUTHORIZATIONI acknowledge that I have received and carefully read and understand the separate Disclosure and Authorization Regarding Background Investigation for Employment Purposes; and the separate Summary of Rights under the Fair Credit Reporting Act that have been provided to me by the Company. I also acknowledge receipt of and that I have carefully read and understand (as applicable), the separate California Disclosure and Summary of Rights under California Civil Code Section 1786.22; the separate New York Article 23-A; and the separate San Francisco Fair Chance Ordinance Official Notice that have been provided to me. By my signature below, I authorize the preparation of background reports about me, including background reports that areinvestigative consumer reports by HireRight, and to the furnishing of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment(including independent contractor or volunteer assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may, as allowed by law, obtain from HireRight (or from a consumer reporting agency other than HireRight) additional background reports pertaining to me, without asking for my authorization again, throughout my employment or contract period. I understand that if the Company obtains a credit report about me, then it will only do so where such information is substantially related to the duties and responsibilities of the position in which I am engaged or for which I am being evaluated. I understand that information contained in my employment (or contractor or volunteer) application, or otherwise disclosed by me before or during my employment (or contract or volunteer assignment), if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services.I understand that the information included in the background reports may be obtained from private and public record sources, including without limitation and as appropriate: government agencies and courthouses; educational institutions; and employers. Accordingly, I hereby authorize all of the following, to disclose information about me to the consumer reporting agency and its agents: law enforcement and all other federal, state and local government agencies and courts; educational institutions (public or private); testing agencies; information service bureaus; credit bureaus and other consumer reporting agencies; other public and private record/data repositories; motor vehicle records agencies; my employers; the military; and all other individuals and sources with any information about or concerning me. The information that can be disclosed to the consumer reporting agency and its agents includes, but is not limited to, information concerning my: employment and earnings history; education, credit, motor vehicle and accident history; drug/alcohol testing results and history; criminal history; litigation history; military service; professional licenses, credentials and certifications; social security number verification; address and alias history; and other information. By my signature below, I also promise that the personal information I provide with this form or otherwise in connection with my background investigation is true, accurate and complete, and I understand that dishonesty or material omission may disqualify me from consideration for employment. I agree that a copy of this document in faxed, photocopied or electronic (including electronically signed) form will be valid like the signed original. I further acknowledge that I have received additional state law notices that I have reviewed and read.California, Minnesota or Oklahoma consumers: Please check this box if you would like to receive (whenever you have such right under the applicable state law) a free copy of your background report if one is obtained on you by the Company. Additional State Law NoticesPlease also note the following:CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by the consumer reporting agency during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the actual copying costs, by appearing at the consumer reporting agencys offices in person, during normal business hours and on reasonable notice, or by certified mail. You may also receive a summary of the file by telephone, upon submitting proper identification and written request. The consumer reporting agency has trained personnel available to explain your file to you, including any coded information, and will provide a written explanation of any coded information contained in your file. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. Proper identification includes documents such as a valid drivers license, social security account number, military identification card, and credit cards. If you cannot identify yourself with such information, the consumer reporting agency may require additional information concerning your employment and personal or family history to verify your identity. HireRight, Inc. (HireRight) will prepare the background report for the Company. HireRight is located and can be contacted at 3349 Michelson Drive, Suite 150, Irvine, CA 92612, (800) 400-2761. Information about HireRights privacy practices is available at www.hireright.com/Privacy-Policy.aspx.Additional California-specific information is set out below. 9 of 12MASSACHUSETTS: Upon request to the Company, you have the right to know whether the Company requested an investigative consumer report about you and, upon written request to the Company, you have the right to receive a copy of any such report. You also have the right to ask the consumer reporting agency (e.g., HireRight) for a copy of any such report. MINNESOTA: You have the right in most circumstances to submit a written request to the consumer reporting agency (e.g., HireRight) for a complete and accurate disclosure of the nature and scope of any consumer report the Company ordered about you. The consumer reporting agency must provide you with this disclosure within 5 days after (i) its receipt of your request or (ii) the date the report was requested by the Company, whichever date is later. NEW JERSEY: You have the right to submit a request to the consumer reporting agency (e.g., HireRight) for a copy of any investigative consumer report the Company requested about you. NEW YORK: You have the right, upon written request to the Company, to be informed of whether or not the Company requested a consumer report or an investigative consumer report about you. Shown above is the address and telephone number for HireRight, the consumer reporting agency used by the Company. You may inspect and receive a copy of any such report by contacting that consumer reporting agency. A copy of Article 23-A of the New York Correction Law is also provided below. WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right, upon written request made to the Company within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation requested by the Company. You are entitled to this disclosure within 5 days after the date your request is received or the Company ordered the report, whichever is later. You also have the right to request a written summary of your rights and remedies under the Washington Fair Credit Reporting Act. Applicant Last Name First Middle Applicant Signature Date 10 of 12Para informacin en espaol, visitewww.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington DC 20552.A Summary of Your Rights Under the Fair Credit Reporting ActThe federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies(such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your file disclosure). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:a person has taken adverse action against you because of information in your credit report;you are the victim of identity theft and place a fraud alert in your file;your file contains inaccurate information as a result of fraud;you are on public assistance;you are unemployed but expect to apply foremployment within 60 days.In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for |
