| Candidate Information | | Title | Human Resources United States | | Target Location | US-IA-Rock Rapids |
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Click here or scroll down to respond to this candidateQLF Transportation, Inc. Driver Application for EmploymentPage 1 of Street Address
Application PacketThank you for choosing QLF Transportation, Inc. as a potential employer. We carefully evaluate each application and select the best qualified candidates for further consideration. Those selected for interviews are contacted by telephone or mail.General InformationQLF Transportation, Inc. is a subsidiary of Quality Liquid Feeds, Inc. We are a family-owned corporation with more than 40 years of experience in liquid feed manufacturing. Our Corporate Office, in Dodgeville, Wisconsin, is headquarters for business services, technical services, marketing, sales, order processing, accounting and distribution, as well as human resources.We have seen continued growth through geographic market expansion, expanded product offerings, improved technical and market services, improved distribution capability and expanded sales force and formation of strategic supplier alliances.QLF Transportation, Inc. supports marketing and distribution of QLF products throughout the United States and portions of Canada.General RequirementsWhile the following is not an all-inclusive list, at a minimum, in order to be considered for employment, applicants must: Be a minimum of 21 years of age; Have a minimum of 1 year verifiable OTR experience o If applicant has less than a minimum of 1 year verifiable OTR experience, completion of a QLF approved Driving School may be substituted for years of experience at the employers discretion. If hired, additional training and orientation would be required as a condition of employment. Have a minimum of 1 year tanker experience (preferred) Have no more than two (2) moving violations in the last three (3) years, with no more than one (1) moving violations within any twelve (12) month period Have no major moving violations; Possess a valid Class A CDL with tanker endorsement; Have the ability to pass DOT physical, drug test and other evaluations; Have NO positive DOT drug or alcohol test of any kind; Have NO DUI, DWI, alcohol-related or reckless convictions in the last seven (7) years, and no more than one (1) in a lifetime; Have no more than two (2) preventable accidents in the last three (3) years; Have positive references with stable work history; and Ability to perform the job requirements with reasonable accommodations. QLF Transportation, Inc. Driver Application for Employment Page 2 of 13Instructions for ApplicationPlease complete the forms throughout this application packet as completely and truthfully as possible. Completed applications can be faxed, mailed or delivered in person to: QLF Transportation, Inc.Attn: Driver Manager3586 State Highway 23 NorthPO Box 240Dodgeville, WI 53533Return Secure Fax:Fax: PHONE NUMBER AVAILABLEWhen submitting your application, please check that you have all of the following items: All questions answered; write NONE if it does not apply Employment Information begin with your current position and work backwards; make sure there are no gaps in employmentApplicants must alert QLF Transportation, Inc. of any changes that may arise regarding their application, such as a change of contact information, as soon as possible, in order for their application to be processed. Please direct all inquiries to our Driver/Safety Manager, Tony Fink, at (608) 935-0915, extension 16. He may also be reached on his cellular phone at (608) 732-4087.QLF Transportation, Inc. Driver Application for Employment Page 3 of 13QLF Transportation, Inc.3586 Highway 23 North, PO Box 240Dodgeville, WI 53533Date of ApplicationWhere did you see our employment ad?QLF Employee Referred by:Driver Application for EmploymentGENERAL INFORMATIONName (Last, First, MI), printed Social Security Number Current Street Address Date of BirthCity State Zip CodeTelephone Number (include Area Code) Length at Current Address (Listed in Number of Months) Email AddressList Address for the Past Three (3) Years:Street Address, City, State Zip Code Length at Address (Listed in Number of Months) Street Address, City, State Zip Code Length at Address (Listed in Number of Months) Driver License Number State ClassEndorsement(s) Expiration DateTanker Endorsement? Yes NoTraffic Convictions and ForfeituresDo you have any traffic convictions and forfeitures within the past three (3) years (other than parking violations)?Yes (if yes, please complete below) NoDate Location Charge PenaltyDriver Past RecordHave you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No Have you ever had any licenses, permit or privilege suspended or revoked? Yes No Have you ever been disqualified for violation(s) of the Federal Motor Carrier Regulations? Yes No If yes to any questions above, please describe:Do you have legal right to work in the United States? Yes No Do you have a CDL? Yes NoDo you have CMV driving experience? Yes NoQLF Transportation, Inc. Driver Application for Employment Page 4 of 13AccidentsHave you been involved in an accident in the past three (3) years? Yes (if yes, please complete below) No Date of Accident Location (City, State)Accident Description (i.e. head-on, rear end, upset, rollover, etc.) Number of Injuries Number of Fatalities Were you DOT Regulation Cited? (If yes, what was the citation?) Hazardous Materials Spill? Yes NoType of Vehicle OperatedDate of Accident Location (City, State)Accident Description (i.e. head-on, rear end, upset, rollover, etc.) Number of Injuries Number of Fatalities Were you DOT Regulation Cited? (If yes, what was the citation?) Hazardous Materials Spill? Yes NoType of Vehicle OperatedDriving ExperienceEquipment Years Miles From(mm/yy)To(mm/yy)Tanker Yes NoRefer Yes NoVan Yes NoDump Yes NoFlat Bed Yes NoOther Yes NoOverall years of Commercial Motor Vehicle Class A driving experience? Overall years of Commercial Motor Vehicle Class A driving experience in snow? List all states and provinces you have operated a commercial motor vehicle in during the past five (5) years. List any other relevant experience.List any safety awards you have received.List courses and training not listed elsewhere on this application. List special equipment or technical materials you can work with not listed elsewhere on this application. EducationCircle the highest grade completed:Grade School: 1 2 3 4 5 6 7 8 High School: 9 10 11 12 College: 1 2 3 4 Name of Last School Attended Location (City, State) QLF Transportation, Inc. Driver Application for Employment Page 5 of 13EMPLOYMENT INFORMATIONList all periods of employment and unemployment, starting with the most recent. CFR 391.51(b) requires 3 years of history to be verified and 7 subsequent years to be recorded for a total of 10 years of employment history, or to the extent of which the applicant has worked. There should be no gaps in employment; if a gap exists, you must indicate a reason.If additional Employment Information spaces are needed, please make a copy of Page 6 of the Driver Application for Employment and attach to your Application.Employer Name Dates From (mm/yy) To (mm/yy)Employer Street Address Position HeldCity State Zip CodeTelephone Number (include Area Code) Type of Tractor(s) Operated Sleeper or Day CabWere you subject to the FMCSR while employed? Yes No Transmission Type of Trailer(s) Operated(10, 13, Other)Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing required by 49 CFR Part 40? Yes No OTR REGIONAL OTR LOCALReason for LeavingIf a gap between employment exists, indicate reason: Unemployed Self-Employed Other Employer Name Dates From (mm/yy) To (mm/yy)Employer Street Address Position HeldCity State Zip CodeTelephone Number (include Area Code) Type of Tractor(s) Operated Sleeper or Day CabWere you subject to the FMCSR while employed? Yes No Transmission Type of Trailer(s) Operated Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing required by 49 CFR Part 40? Yes No OTR REGIONAL OTR LOCALReason for LeavingIf a gap between employment exists, indicate reason: Unemployed Self-Employed Other Employer Name Dates From (mm/yy) To (mm/yy)Employer Street Address Position HeldCity State Zip CodeTelephone Number (include Area Code) Type of Tractor(s) Operated Sleeper or Day CabWere you subject to the FMCSR while employed? Yes No Transmission Type of Trailer(s) Operated Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing required by 49 CFR Part 40? Yes No OTR REGIONAL OTR LOCALReason for LeavingIf a gap between employment exists, indicate reason: Unemployed Self-Employed Other QLF Transportation, Inc. Driver Application for Employment Page 6 of 13Employer Name Dates From (mm/yy) To (mm/yy)Employer Street Address Position HeldCity State Zip CodeTelephone Number (include Area Code) Type of Tractor(s) Operated Sleeper or Day CabWere you subject to the FMCSR while employed? Yes No Transmission Type of Trailer(s) Operated Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing required by 49 CFR Part 40? Yes No OTR REGIONAL OTR LOCALReason for LeavingIf a gap between employment exists, indicate reason: Unemployed Self-Employed Other Employer Name Dates From (mm/yy) To (mm/yy)Employer Street Address Position HeldCity State Zip CodeTelephone Number (include Area Code) Type of Tractor(s) Operated Sleeper or Day CabWere you subject to the FMCSR while employed? Yes No Transmission Type of Trailer(s) Operated Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing required by 49 CFR Part 40? Yes No OTR REGIONAL OTR LOCALReason for LeavingIf a gap between employment exists, indicate reason: Unemployed Self-Employed Other Employer Name Dates From (mm/yy) To (mm/yy)Employer Street Address Position HeldCity State Zip CodeTelephone Number (include Area Code) Type of Tractor(s) Operated Sleeper or Day CabWere you subject to the FMCSR while employed? Yes No Transmission Type of Trailer(s) Operated Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing required by 49 CFR Part 40? Yes No OTR REGIONAL OTR LOCALReason for LeavingIf a gap between employment exists, indicate reason: Unemployed Self-Employed Other Employer Name Dates From (mm/yy) To (mm/yy)Employer Street Address Position HeldCity State Zip CodeTelephone Number (include Area Code) Type of Tractor(s) Operated Sleeper or Day CabWere you subject to the FMCSR while employed? Yes No Transmission Type of Trailer(s) Operated Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing required by 49 CFR Part 40? Yes No OTR REGIONAL OTR LOCALReason for LeavingIf there is additional employment history. Please make a copy of this page to continue. QLF Transportation, Inc. Driver Application for Employment Page 7 of 13QLF Transportation, Inc.3586 Highway 23 North, PO Box 240Dodgeville, WI 53533APPLICANT CERTIFICATIONBy signing this statement, I certify: This application for employment was completed by me and that all entries on it and the information contained within are true to the best of my knowledge; and As required by Section 383.21 of the FMCSR, I only have one motor vehicle operators license. Furthermore, I authorize Quality Liquid Feeds, Inc. or its agencies 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 any and all of the employers, school, health care providers, QLF Transportation, Inc. and their subsidiaries, as well as the persons associated with this application for employment and the subsequent processes and procedures from all liability in response to inquiries and releasing of information 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 be considered fraud and could be construed as criminal and may be grounds for termination and permanent discharge from this company. I understand that I am required to abide by all rules and regulations of the company as outlined in the company policies and statements. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: Review information provided by previous employers; Have errors in the information corrected by previous employers and for those previous employers to resend the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, if previous employer(s) and I cannot agree on the accuracy of the information.Applicant Signature DateQLF Transportation, Inc. is an equal Opportunity Employer. QLF Transportation, Inc. does not discriminate on the basis of race, color, religion, age, sexual orientation, national origin or ancestry, physical or mental disability, marital status, pregnancy, veteran status, medical condition or any other protected status as defined by law. QLF Transportation, Inc. Driver Application for Employment Page 8 of 13QLF Transportation, Inc.3586 Highway 23 North, PO Box 240Dodgeville, WI 53533REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYERSBy signing below, I acknowledge and authorize the release of the following information for the purposes of investigation to QLF Transportation, Inc., as required by Section 391.23 and allowed by Section 383.35 of the Federal Motor Carrier Safety Regulations. I fully understand and do hereby give my consent to obtain the information required by 49 CFR 382.413. You are released from any and all liability that may result from furnishing such information.Printed Name DateApplicant Signature SSNAPPLICANT: DO NOT COMPLETE BELOW THIS LINECompanys Name PhoneAddress Fax or EmailThe applicant named above was employed by us: Yes No Position Held From (mm/dd/yyyy) To (mm/dd/yyyy)Did he/she driver motor vehicles for you? Yes No If yes, what type?Class A Tractor-Trailer Straight Truck Tanker Van Refer Livestock Flat BedOther (specify) Reason for Leaving? Resignation Discharge Lay-Off Military Duty Other (specify) Eligible for rehire? Yes Review NoDid applicant give a 2-week notice? Yes NoQLF Transportation, Inc. Driver Application for Employment Page 9 of 13Applicants Name SSNAPPLICANT: DO NOT COMPLETE BELOW THIS LINEIf there is no safety performance history to report, check here, sign below and return. ACCIDENT HISTORYAccidents: Complete the following for any accidents included on your accident register that involved the applicant or check here if there is no accident register data for this person. Date Location No. of Injuries No. of Fatalities Hazmat Spill Please provide information concerning any other accidents involving the applicant that were reported to government agencies, insurers or retained under company policy. DRUG AND ALCOHOL HISTORYIf the driver was not subject to Department of Transportation testing requirements while employed by you, please check here .Driver was subject to DOT testing requirements from to . Yes NoHas this person had an alcohol test with a result of 0.04 alcohol concentration or greater? Has this person tested positive or adulterated or substituted a test specimen for a controlled substance?Has this person refused to submit a post-accident random, reasonable suspicion, or follow-up alcohol or controlled substance test?Has this person committed other violations of Subpart B of Part 382, or Part 40? Did a previous employer report a drug and alcohol rule violation to you? If this person violated a drug and alcohol regulation, did this person complete a SAP-prescribed rehabilitation program in your employ, including return-to-duty and follow-up tests? If so, please send documentation back with this form.For a driver who successfully completed a SAPs rehabilitation referral and remained in your employ, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test or a refusal to be tested?In answering these questions, include any DOT drug and alcohol testing information obtained from previous employers in the previous 3 years. Indicate their contact information below: Company Name/Address PhoneCompleted By DateQLF Transportation, Inc. Driver Application for Employment Page 10 of 13QLF Transportation, Inc.3586 Highway 23 North, PO Box 240Dodgeville, WI 53533REQUEST FOR CHECK OF DRIVING RECORDI hereby authorize Hire Right to generate a Motor Vehicle Report and provide it to QLF Transportation, Inc. for the purpose 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 that may result from furnishing such information. Applicants Signature DatePrinted Name Date of BirthDriver License Number Expiration DateDrivers SSNFAIR CREDIT REPORTING ACT DISCLOSURE STATEMENTIn accordance with the provisions 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 I, of Public Law 104-208), you are being informed that consumer reports verifying your previous employment, drug and alcohol test results, and driving record may be obtained on you for employment purposes.I acknowledge the receipt of the above disclosure and authorize QLF Transportation, Inc. to obtain consumer reports on me for employment purposes. The authorization is ongoing in the event such a report is needed in the future. Applicant Signature DateQLF Transportation, Inc. Driver Application for Employment Page 11 of 13QLF Transportation, Inc.3586 Highway 23 North, PO Box 240Dodgeville, WI 53533AUTHORIZATION FOR RELEASE OF RECORDSIn accordance with the provisions 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 I, of Public Law 104-208), you are being informed that a consumer report may be obtained on you for employment purposes. In addition, QLF Transportation, Inc. may also request additional reports for the purposes of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations.My signature below indicates that you are authorized to provide such reports and are released from any and all liability which may result from furnishing such information.I acknowledge receipt of the above disclosure and authorize QLF Transportation, Inc. to obtain reports and conduct investigations on me for employment purposes. The authorization is ongoing in the event such a report is needed in the future. Applicant Signature DateIn accordance with the provisions of the Fair Credit Report Act (Public Law 91-508), I hereby certify that the information requested below will be used for permission purposes as defined in the Act.Furthermore, if the applicant named below is denied employment based on the information received, I will identify the source of the report in accordance with the Act.QLF, Transportation, Inc.Signature of Requestor Name of Company3586 Highway 23 NorthPrinted Name & Title Street AddressDodgeville, WI 53533Date City, State Zip CodeName of ApplicantStreet Address City, State Zip CodeFormer Street Address Former City, State Zip CodeSSN License Number State Date of BirthQLF Transportation, Inc. Driver Application for Employment Page 12 of 13THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERSIMPORTANT DISCLOSUREREGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with __QLF Transportation 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. The Prospective Employer cannot obtain background reports from FMCSA without your authorization. AUTHORIZATIONIf you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:I authorize __QLF Transportation 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.QLF Transportation, Inc. Driver Application for Employment Page 13 of 13I 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: SignatureName (Please Print)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 Applicants written or electronic consent prior to accessing the Applicants PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicants 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. LAST UPDATED 12/22/2015 |
