Name*
First
Middle
Last
Home Phone
Cell Phone*
Email*
Present Address*
How Long?
Previous Address
How Long?
Previous Address
How Long?
Date of birth (Reqd's by DOT)*
Name of relatives in our employment
How did you hear of us?
Recruiter
A. Have you ever been denied a license, permit or privilege vehicle?* B. Has any license, permit or privilege been suspended or revoked?* C. Have you been convicted, or are charges pending for reckless or careless operation of a vehicle?* D. Have you ever been denied bonding? E. Have you ever been convicted for possession, sale, or use to operate a motor drug, amphetamine, or a derivative thereof?* F. Are any charges pending or have you been convicted for for driving under the influence of alcohol, a narcotic drug, Amphetamines or derivatives thereof?* G. Have you ever been convicted of a felony? (A conviction will not necessarily bar from employment.)* H. Have you ever tested positive or refused a pre-employment drug test for a job where you were not hired?* IF ANSWER IS YES TO ANY OF THE ABOVE, state circumstances and dates Education* Select Highest Grade Complete
College completed* Select highest degree obtained
Military Record Branch
Dates enlisted
Attach DD214 Accepted file extensions: jpg, png, pdf
MOTOR VEHICLE LICENSES {List all Driver Licenses held in the past 10 years)* TRAFFIC CONVICTIONS (List all Traffic Convictions in the past 5 years) IF NONE, WRITE NONE.* ACCIDENT RECORD (List all accidents/incidents in any motor vehicle in the past 5 years; preventable or non-preventable) IF NONE, WRITE NONE.* DRIVING EXPERIENCE EMPLOYMENT HISTORY
In accordance to FMCSA Subpart C § 383.35 Complete the following information regarding your employment history during the past •(ten) years
including any time you were self-employed or unemployed. If you have had your CDL for 3 {three) years or less, provide only 3 {three) years employment
history including any time you were self-employed or unemployed. Attach additional pages if necessary in the same application format, a resume' is NOT
acceptable. Start with your current employment or unemployment. Period of Unemployment (if any) From (month/year) NOTE: ALL unemployment periods are required to be verified by Gholia Bros Trucking LLC.
Date Format: DD slash MM slash YYYY
Period of Unemployment (To Date)
Date Format: DD slash MM slash YYYY
Company Name
Position Held
Employment Date From
Date Format: MM slash DD slash YYYY
Employment Date To
Date Format: MM slash DD slash YYYY
Phone No
Address
Untitled Salary
No of Supervisor
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Was your job designated as a safety-sensitive function in ay DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR, Part 40? Period of Unemployment (if any) From (month/year) NOTE: ALL unemployment periods are required to be verified by Gholia Bros Trucking LLC.
Date Format: DD slash MM slash YYYY
Period of Unemployment (To Date)*
Date Format: DD slash MM slash YYYY
Company Name
Position Held
Employment Date From
Date Format: MM slash DD slash YYYY
Employment Date To
Date Format: MM slash DD slash YYYY
Phone No
Address
Untitled Salary
No of Supervisor
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Was your job designated as a safety-sensitive function in ay DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR, Part 40? Period of Unemployment (if any) From (month/year) NOTE: ALL unemployment periods are required to be verified by Gholia Bros Trucking LLC.
Date Format: DD slash MM slash YYYY
Period of Unemployment (To Date)
Date Format: DD slash MM slash YYYY
Company Name
Position Held
Employment Date From
Date Format: MM slash DD slash YYYY
Employment Date To
Date Format: MM slash DD slash YYYY
Phone No
Address
Untitled Salary
No of Supervisor
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Was your job designated as a safety-sensitive function in ay DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR, Part 40? Period of Unemployment (if any) From (month/year) NOTE: ALL unemployment periods are required to be verified by Gholia Bros Trucking LLC.
Date Format: DD slash MM slash YYYY
Period of Unemployment (To Date)
Date Format: DD slash MM slash YYYY
Company Name
Position Held
Employment Date From
Date Format: MM slash DD slash YYYY
Employment Date To
Date Format: MM slash DD slash YYYY
Phone No
Address
Untitled Salary
No of Supervisor
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Was your job designated as a safety-sensitive function in ay DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR, Part 40? Period of Unemployment (if any) From (month/year) NOTE: ALL unemployment periods are required to be verified by Gholia Bros Trucking LLC.
Date Format: DD slash MM slash YYYY
Period of Unemployment (To Date)
Date Format: DD slash MM slash YYYY
Company Name
Position Held
Employment Date From
Date Format: MM slash DD slash YYYY
Employment Date To
Date Format: MM slash DD slash YYYY
Phone No
Address
Untitled Salary
No of Supervisor
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Was your job designated as a safety-sensitive function in ay DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR, Part 40? Period of Unemployment (if any) From (month/year) NOTE: ALL unemployment periods are required to be verified by Gholia Bros Trucking LLC.
Date Format: DD slash MM slash YYYY
Period of Unemployment (To Date)
Date Format: DD slash MM slash YYYY
Company Name
Position Held
Employment Date From
Date Format: MM slash DD slash YYYY
Employment Date To
Date Format: MM slash DD slash YYYY
Phone No
Address
Untitled Salary
No of Supervisor
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Was your job designated as a safety-sensitive function in ay DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR, Part 40? Period of Unemployment (if any) From (month/year) NOTE: ALL unemployment periods are required to be verified by Gholia Bros Trucking LLC.
Date Format: DD slash MM slash YYYY
Period of Unemployment (To Date)
Date Format: DD slash MM slash YYYY
Company Name
Position Held
Employment Date From
Date Format: MM slash DD slash YYYY
Employment Date To
Date Format: MM slash DD slash YYYY
Phone No
Address
Untitled Salary
No of Supervisor
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Was your job designated as a safety-sensitive function in ay DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR, Part 40? Period of Unemployment (if any) From (month/year) NOTE: ALL unemployment periods are required to be verified by Gholia Bros Trucking LLC.
Date Format: DD slash MM slash YYYY
Period of Unemployment (To Date)
Date Format: DD slash MM slash YYYY
Company Name
Position Held
Employment Date From
Date Format: MM slash DD slash YYYY
Employment Date To
Date Format: MM slash DD slash YYYY
Phone No
Address
Untitled Salary
No of Supervisor
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Was your job designated as a safety-sensitive function in ay DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR, Part 40? Period of Unemployment (if any) From (month/year) NOTE: ALL unemployment periods are required to be verified by Gholia Bros Trucking LLC.
Date Format: DD slash MM slash YYYY
Period of Unemployment (To Date)
Date Format: DD slash MM slash YYYY
Company Name
Phone No
Employment Date From
Date Format: MM slash DD slash YYYY
Employment Date To
Date Format: MM slash DD slash YYYY
Position Held
Address
Untitled Salary
No of Supervisor
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Was your job designated as a safety-sensitive function in ay DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR, Part 40? Period of Unemployment (if any) From (month/year) NOTE: ALL unemployment periods are required to be verified by Gholia Bros Trucking LLC.
Date Format: DD slash MM slash YYYY
Period of Unemployment (To Date)
Date Format: DD slash MM slash YYYY
Company Name
Phone No
Employment Date From
Date Format: MM slash DD slash YYYY
Employment Date To
Date Format: MM slash DD slash YYYY
Position Held
Address
Untitled Salary
No of Supervisor
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Was your job designated as a safety-sensitive function in ay DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR, Part 40? Period of Unemployment (if any) From (month/year) NOTE: ALL unemployment periods are required to be verified by Gholia Bros Trucking LLC.
Date Format: DD slash MM slash YYYY
Period of Unemployment (To Date)
Date Format: DD slash MM slash YYYY
Company Name
Phone No
Position Held
Employment Date From
Date Format: MM slash DD slash YYYY
Employment Date To
Date Format: MM slash DD slash YYYY
Address
Untitled Salary
No of Supervisor
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Was your job designated as a safety-sensitive function in ay DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR, Part 40? TO BE READ AND SIGNED BY APPLICANT:
• Understand that Gholia Bros. Trucking, LLC. is under no obligation to hire me and that any employment I am offered is 'at-will' as stated in the "Application for Employment'. Date
Date Format: MM slash DD slash YYYY
Signature*
Please type your full legal name
Gholia Bros Trucking
Gholia Bros Trucking is making this contract offer based on your qualifications as represented in the in your contractor application. Accepted by:
Date
Date Format: MM slash DD slash YYYY
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS
IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with GhoIia Bros. LLC ("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 htiptridataqs.fincsa.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.
AUTHORIZATION
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Gholia Bros. Trucking,LLC ("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.
I 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 hups://dataqs.fincsa.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 psr. 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, andlor affiliates to obtain the information authorized above.
Date
Date Format: MM slash DD slash YYYY
Signature*
Please type your full legal name
Name
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 Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant's 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.
NOTICE: The prospective employment concept referenced in this form contemplates the definition of "employee" contained at 49 C.F.R. 383.5.
LAST UPDATED 2/1112016
DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23
Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January I,1971.
• (ax I) An inquiry into the driver's driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator's license or permit during those three years; and • (a)(2) An investigation of the driver's employment record during the preceding three years.
• (b) A copy of the driver records) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver's employment begins and be retained in compliance with 391.51.
• (c) Replies to the investigations of the driver's safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver's employment begins. This goes into effect after October 29, 2004.
• (d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.
• (e) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.
Drivers have the following rights:
I. The right to review information provided by previous employers.
2. 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.
3. 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. Drivers who wish to review previous employer.
•Provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.
Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver's request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver's Safety Performance History.
I acknowledge that I have read and understand the contents of this document
Driver Signature*
Please type your full legal name
Date
Date Format: MM slash DD slash YYYY
Driver Name
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 ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and persons named here inform all liability for any damages on account of his furnishing such information.
It is also agreed and understood that under the Fair Credit Reporting Acr, Public Law 91408, 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 for Qualification 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 / 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*
Please type your full legal name
Date
Date Format: MM slash DD slash YYYY
DRIVER APPLICANT DRUG AND ALCOHOL PRE-EMPLOYMENT STATEMENT
CFR Part 40.250) requires the employer to ask any applicant, whether he or she has tested positive, or refused
to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, we must not use the employee to perform safety-sensitive functions, until and unless the potential employee provides documentation of successful completion of the return-to-duty process.
(See Section 40.25(b)(5) and (e).
Applicant Name
(Please Print)
ID Number:
As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part
40.25(j) to respond to the following questions. My signature below certifies that the information provided is true and correct.
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?* If you answered yes, to the above question, can you provide proof that you have successfully completed the DOT return-to-duty requirements?* Applicant Signature*
Date*
Date Format: MM slash DD slash YYYY
Seven Day Prior Log Form
(Data sheet for new, casual, or temporary drivers)Name
SOC. SEC.#
Address
Phone
DRIVERS LICENSE #:
STATE
Instructions:
DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 I hereby certify that the information given above is correct to the best of my knowledge and belief and that I was last relieved from work at: Time On Date
Date Format: MM slash DD slash YYYY
Signature*
Please type your full legal name
Date
Date Format: MM slash DD slash YYYY
VIOLATION AND REVIEW RECORD Driver's Name:*
Contractor Number
CERTIFICATION OF VIOLATIONS
I certify that the following is a true and complete list of all traffic violations (including revocation, suspension or withdrawal
of an operator's licens)Operator's License:
Date Format: MM slash DD slash YYYY
(Revoked, Suspended, or Withdrawn)
Restored
License Number:
State:
Expiration Date:
Date Format: MM slash DD slash YYYY
If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral, during the past 12
months, because of any violation required to be listed. Contractor's Signature
Date
Date Format: MM slash DD slash YYYY
Reviewed By
Date
Date Format: MM slash DD slash YYYY
REVIEW AND EVALUATION OF DRIVER'S RECORD
In accordance with Section 391.25 of the Federal Motor Carrier Safety Regulations, all information pertinent to the above driver's safety of operations, including the list of violations furnished by him/ her in accordance with Section 391.27, has been reviewed for the past 12 months. Actions taken are detailed below (and on the reverse side of this form if additional
room was necessary).
By signing this Release of Information form, you hereby authorize, without liability, Gholia Bros.
Trucking, LLC. (herein referred to "GHOLIA BROS.") to contact any person or organization whose
name you have given as reference or by whom you have been previously employed. You hereby
authorize your previous employer to release and forward all information regarding your duties,
character, conduct, accident history and any Alcohol and Controlled Substances Testing /Training
records while in you were employed.
You hereby authorize GHOLIA BROS. to obtain and review your credit report/background. Your credit report/background will be obtained from a credit
reporting agency chosen by GHOLIA BROS. You understand and agree that GHOLIA BROS. intends to
use the credit report for the purpose of evaluating your employment ability.
You hereby release all
persons and organizations from any claims for damages of any kind which may occur to you by
reasons for furnishing such information.
You acknowledge that you may be required and agree to submit to drug and alcohol testing as part of the employment process, and authorize release of
your results to GHOLIA BROS., and agree that any offer will be contingent on the results.
You hereby authorize all past employers to release the following information to GHOLIA BROS. for
purposes of investigations as required by Section 391.23 and 382.413 of the Federal Motor Carrier
Safety Regulations. These employers are released from any and all liability that may result from
furnishing such information.
You authorize any law enforcement agency or court of record to
furnish GHOLIA BROS. information concerning Motor Vehicle Record, CSA scores with the use of
the PSP, or any felony or misdemeanor of which you have been convicted.
You acknowledge and
agree that you will familiarize yourself with and abide by all present and subsequently issued rules,
policies, or procedures of GHOLIA BROS.
Name*
Social Security Number*
Signature*
Date of Birth*
Date*
Date Format: MM slash DD slash YYYY
PAST EMPLOYMENT VERIFICATION
Gholia Bros. Trucking, LLC I hereby authorize you to release the following formation to Gholia Bros. Trucking LLC. for purposes of investigations as required by
section 391.23 and 382.413 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability that may result
from furnishing such information.
I hereby authorize my previous employer to release and forward all information regarding my duties, character, conduct, accident
history, and any Alcohol and Controlled Substances Testing/Training records while in your employ. SS#:*
FULL NAME*
Date*
Date Format: MM slash DD slash YYYY
SIGNATURE*
