Driver Qualification Job Application

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Driver Qualification Job Application Powered By Docstoc
					                                        Driver Qualification Application
                                                  Take to the fuel counter at any Loves, Pilot, Bosselmans & Town Pump
888.832.6484 (phone)
                                                   truck-stops to be scanned directly to Gordon Trucking at no charge.
 866.804.0715 (fax)                                                  Do not scan this page. Begin scan on Page 2.
www.teamgti.com (chat)

                                   Call us today at: 888.832.6484
                         Your Recruiter is ________________________ extension ________

                                                           Terminal Locations
     1 Pacific, WA                                     4 Modesto, CA                                              7 Green Bay, WIDrive
                                                                                                                    1135 Contract
          Corporate Office                                  3090 Farrar Avenue
          151 Stewart Road S.W.                             Modesto, CA 95354                                          Green Bay, Wisconsin 54304
          Pacific, Washington 98047
          Clackamas, OR                                     Rancho Cucamonga, CA                                  8 Indianapolis, IN
                                                                                                                    5723 West Dividend Road
     2                                                 5    8566 Pecan Avenue                                          Indianapolis, Indiana 46241
          15628 S.E. 102nd Avenue
          Clackamas, Oregon 97015                           Rancho Cucamonga, CA 91739
 3


     3 Medford, OR                                               AZ
                                                       6 Phoenix,Grant St.
                                                         6602 W.
          1923 Sage Road
          Medford, Oregon 97501                             Phoenix, A Z 85043



                         DRIVER Q UALIFICATION A PPLICATION I NSTRUCTIONS
     1.   The information you supply on your application must be printed in ink in your own handwriting. Please answer all questions on the application form.
          PLEASE PRINT LEGIBLY. DO NOT SEND ANY MEDICAL INFORMATION WITH THIS APPLICATION. Read and follow all instructions carefully.

     2.   VERY IMPORTANT! The section entitled “Employment Record” must be completed correctly. You must list all
          employers, schools, military service, and all periods of self-employment or unemployment for the most recent 10 full years.
          Dates, phone numbers, and addresses must be correct with no period of time unaccounted for in the last 10 years.

     3.   In the section entitled “Drivers License,” list all licenses held in the past seven (7) years. In the sections entitled “Traffic Convictions
          and Forfeitures” and “Accident Record,” list all tickets and forfeitures and all accidents for the past three (3) years.
               List all accidents regardless of fault, severity, or motor vehicle type, be it personal vehicle or
               business vehicle. We will check your motor vehicle report for the past 10 years, so please be accurate.

     4.   The section entitled “Notice, Authorization and Release for Pre-employment Inquiries” must be signed, initialed and dated.

     5.   Please sign and date the Application at the bottom of both page 6 and top of page 7.

     6.   Any offer of employment will be conditioned upon successfully completing:
          a D.O.T. physical and company medical screening; drug screen; criminal background check; and company road test.


            To speed up the application process, please attach COPIES, not originals, of the following documents.

     1. Class A CDL
     2. Motor Vehicle Report (driving record)
     3. Accident Report (if accident occurred in the last 3 years)
     4. DD214 (if prior military service within the past 5 years)                                    For Gordon Trucking use only
     5. School Certificate and Transcripts (if attended in the past 3 years)
                                                                                                     Applicant Hired: _____________________
     6. Verification of Unemployment (pay records or professional references*)
     7. Verification of Self-employment (tax records or professional references*)                    Date Employed: _____________________
     8. W-2 Forms (if employed by a company that has gone out of business)
                                                                                                     Department: ________________________
     * Professional references: Doctor, Attorney, Minister, Judge, etc.
 DRIVER Q UALIFICATION A PPLICATION
                          Please print in ink in your own handwriting.
                                                                                                                                                          888.832.6484 (phone)
             Note: Please answer or check all questions. If the answer to any question is “No” or “None,”                                                  866.804.0715 (fax)
    do not leave the item blank, indicate “No” or “None.” This application will not be considered unless complete.
                                                                                                                                                     Date: _____________________
Applicant’s Name:         Last __________________________________________________ First ________________________________________ Middle ____________________
Driver Qualification Status Applied for with Gordon Trucking Inc. 151 Stewart Road S.W. Pacific, Washington 98047
   Student Driver
   Company Driver: Fleet _______________________________________________________________
     Owner-Operator:      Individual or business name   ______________________________________________ Phone: (_____)________________
                          Address   ________________________________________City ________________ State ____________ Zip __________
     Contractor Driver:                                                                             Phone: (_____)_________________
                          Name of employing contractor __________________________________________________________________________________

                          Contractor’s Address   __________________________________City ________________ State ____________ Zip __________
Social Security Number:                                      —                       —                                           Date of Birth: __________________________

Present Address:                                                                                                                                       _______ Zip __________________
                      _______________________________________________________________________________City ___________________________ State _____________


How Long There? Years _____________ Months _____________         Home Phone: (_____)_________________________
Cellular Phone Number: _________________________________E-Mail Address: ______________________________________________
In Case of Emergency Notify: Name __________________________________________ Relationship _____________________Address _______________________________________________________
Are you authorized to work in the United States?                  Yes         No                                       Emergency Phone Number:   (_____) ______________________
Is there any reason that you would be denied entry into Canada or Mexico?                          Yes            No   Why? ______________________________________
If you are a resident alien, please give your alien number from your Resident Alien Card, Form I-551: ____________________________________
Have you ever applied to be qualified as a driver by Gordon Trucking?    Yes      No      If so, when _______________
How did you first learn of Gordon Trucking?                   Equipment             Friend            Magazine Ad            Relative             Newspaper Ad
                                                              Website               GTI Driver                    Other _________________________________________
If referred by a Gordon Trucking driver, list his or her name: ________________________ Name of your Recruiter: ______________________

                                                                     PLEASE READ CAREFULLY
A. Have you EVER been denied a license, permit, or privilege to operate a motor vehicle?........................................................................... Yes.............      No
B. Has your motor vehicle operator’s license, permit, or privilege been suspended or revoked? ................................................................ Yes.............           No
C. Have you EVER been disqualified from driving a motor vehicle under the D.O.T. regulations? ................................................................ Yes.............           No
D. Have you EVER been convicted for driving under the influence of alcohol or drugs?................................................................................ Yes.............     No
E. Have you EVER been convicted for possession, sale, or use of a controlled substance? [date _____________ ].............................. Yes.............                              No
F. Have you EVER been convicted of a serious traffic violation, such as careless or reckless driving or willful reckless driving, etc.?.......... Yes.............                        No
G. Have you EVER been convicted of, found not guilty by reason of insanity, plead guilty, or plead no contest for, or been released from prison and/or
   jail for a felony (as defined by any U.S. or state law) at any time during the ten (10) years before the date of this application?............. Yes.............                       No
H. Are you under indictment or charged for a felony or are you required to register as a sex offender (as defined by any U.S. or state law)?
   * Note: A felony conviction will not automatically disqualify you from employment.................................................................................. Yes.............   No
I. Pursuant to D.O.T. regulations have you, within the three (3) years preceding the date of this application:
   (1) Undergone an alcohol test in which a concentration of 0.04 or greater has been indicated?. ........................................................ Yes.............               No
   (2) Undergone a controlled substance test in which a positive result has been verified?. ..................................................................... Yes.............        No
   (3) Refused to undergo either an alcohol or drug test or had an adulterated or substituted drug test verified? .................................. Yes.............                     No
   (4) Had any other violations of Federal Motor Carrier Safety Administration drug or alcohol regulations? ......................................... Yes.............                    No
   (5) Successfully completed return-to-duty requirements following violation of a D.O.T drug or alcohol regulation? .......................... Yes.............                          No
          * This includes all D.O.T. regulated alcohol and drug testing including any pre-employment testing.
IF YOU ANSWERED “YES” TO ANY OF THESE QUESTIONS, PLEASE PROVIDE DETAIL, INCLUDING DATES.



2                                                                                  Version 3, Revision 4, 7 /10
                          EMPLOYMENT RECORD FOR PAST 10 YEARS
                          EMPLOYMENT RECORD FOR PAST 10 YEARS
Begin with your current or most recent job and work backwards in order, listing your employers and any periods of
                        EMPLOYMENT RECORD FOR PAST 10 YEARS
Begin with your current or most recent job and work backwards in order, listing your employers and any periods of
unemployment for at least 10 years including all full and part-time employment. All time must be accounted for,
unemployment for at least 10 years including all full and part-time employment. All time must be accounted for,
including militarycurrent school, self-employment, and periods of unemployment. Use supplementary sheets if necessary.                                     888.832.6484 (phone)
Begin with your service, school, recent job and work periods of in order, listing your employers and any periods of
                        EMPLOYMENT RECORD FOR PAST 10 YEARS
including military service,or most self-employment, and backwardsunemployment. Use supplementary sheets if necessary.                                      888.832.6484 (phone)
                                                                                                                                                             866.804.0715 (fax)
unemployment for at least 10 years including all full and part-time employment. All time must be accounted for,
Begin with your current   EMPLOYMENT RECORD FOR PAST 10 YEARS
                            school, recent job and work periods of in order, listing your employers and any periods of
including military service,or most self-employment, and backwardsunemployment. Use supplementary sheets if necessary.
                                                                   CURRENT EMPLOYER
                                                                                                                                                           888.832.6484 (phone)
                                                                                                                                                             866.804.0715 (fax)
unemployment for at least 10 years including all full and part-time employment. All time must be accounted for,
including military        EMPLOYMENT RECORD FOR PAST 10 YEARS
            Month service, school, self-employment, and periods of unemployment. Use supplementary sheets if necessary.
            your       Year
                       Year                 Month
                                            Month       Year
                                                                    Company
Begin with Month current or most recent job and work backwards in Name:____________________________________________________________
                                                        Year        Company order, listing your employers and any periods of
                                                                               Name:____________________________________________________________
                                                                   CURRENT EMPLOYER
                                                                                                                                                           888.832.6484 (phone)
                                                                                                                                                             866.804.0715 (fax)
unemployment for at least To: ______________
From: ______________ 10 years including all full and part-time employment. All time must be accounted for,
From: ______________ To: ______________ Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
            your        _)EMPLOYMENT RECORD FOR PAST 10 YEARS
Phone with Month (____ or ____________________ CURRENT EMPLOYER supplementary sheets____________________ State _______________ Zip ____________________
including military service, most recent job and work periods of in Street_____________________________________ City periods of
Begin Number: current school, self-employment, and backwardsunemployment. Use employers and any if necessary.
                       Year                 Month       Year        Address: order, listing your
                                                                    Company Name:____________________________________________________________              888.832.6484 (phone)
From: Equipment Driven: ____________________
Phone Number: (____ least 10 years including all full and part-time employment. All time must be accounted for, Satellite Communication: (fax) No
unemployment for at_) ____________________ Position Held: ________________________________
Type of  ______________ To: ______________                                                                                                                   866.804.0715
                                                                                                                                                                                    Yes
                                                                    Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
Type ofNumber: (____ or ____________________ CURRENT EMPLOYER supplementary sheets if necessary. Satellite 888.832.6484 (phone) No
Begin with Month current ____________________ Position Held: ________________________________
including military service, school, self-employment, and backwardsunemployment. Use employers and any periods of
Phone   Equipment Driven: most recent job and work periods of in order, listing your
            your       Year
                        _)                  Month       Year        Company Name:____________________________________________________________              Communication: Yes
  ______________________________________
unemployment for at least To: ______________ Reason For employment. All time must be accounted for, Satellite Communication:
From: ______________ 10 years including all full and part-time Leaving: ______________________ Areas In Which You866.804.0715 (fax) No
  ______________________________________ PositionFor o No           Reason Held: ________________________________
                                                                                                                                                                     _
                                                                                                                                                              Drove: _______________
                                                                                                                                                                                    Yes
Were youEquipment Driven: ____________________ SECONDYes Leaving: ______________________ Areas In Which _______________ Zip ____________________
Type of subject to DOTYear
            Month                                                   Address: Name:____________________________________________________________
including military service, school, while working for this employer? of o Street_____________________________________ City ____________________ State 888.832.6484 (phone)
                        regulations self-employment, and periods unemployment. Use supplementary sheets if necessary.
                                            Month       Year        Company LAST EMPLOYER
                                                                                                                                                         You Drove:________________
Phone Number: (____     _) ____________________ CURRENT EMPLOYER
  ______________________________________ Reason For to DOT drug and alcohol testing? o Yes o No
Were you required to perform safety sensitive functions (such as driving) subject Leaving: ______________________ Areas In Which You866.804.0715 (fax)
From: Equipment Driven: ____________________ SECOND LAST EMPLOYER                                                                                                    _
                                                                                                                                                              Drove: _______________
Type of ______________ To: ______________ Position Held: ________________________________ Satellite Communication:
            Month      Year                 Month       Year        Address: Name:____________________________________________________________                                      Yes      No
                                                                    CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
            Month
Phone Number: (____     _) ____________________ SECOND Name:____________________________________________________________
                       Year
  ______________________________________
                                            Month       Year        Company LAST EMPLOYER
                                                                   CURRENT EMPLOYER
From: ______________ To: ______________ Reason For Leaving: ______________________ Areas In Which You Drove: _______________
                                                                               Name:____________________________________________________________                     _
From: Equipment Driven: ____________________ CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
            Month      Year                 Month       Year
Type of ______________ To: ______________ Address: Held: ________________________________ Satellite Communication:
            Month      Year                 Month       Year
                                                                    Position Street_____________________________________ City ____________________ State _______________ Zip ____________________
                                                                    Address:
                                                                    Company Name:____________________________________________________________
                                                                                                                                                                                    Yes      No
Phone ______________ To: ______________ SECONDStreet_____________________________________ City ____________________ State _______________ Zip ____________________
From: Number: (____
            Month (____
Phone Number:           _) ____________________
                       Year                 Month
                        _) ____________________
                                                        Year
                                                                               LAST EMPLOYER
  ______________________________________                            Address:For Leaving: ______________________ Areas In Which You Drove:________________
From: ______________ To: ______________ Reason Held: ________________________________ Satellite Communication:
From: Equipment Driven: ____________________ Position Held: ________________________________ Satellite Communication:
         ______________ To: ______________ Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________            Yes      No
Type of Equipment Driven: ____________________
Phone Number: (____
Type of                 _) ____________________ Position Street_____________________________________ City ____________________ State _______________ Zip ____________________
                                                                    Address:                                                                                                        Yes      No
            Month
Phone Number: (____
Phone Number: (____     _) ____________________ SECOND Name:____________________________________________________________
                                                                    Company LAST EMPLOYER
                       Year                 Month
                        _) ____________________
                                                        Year
  ______________________________________ PositionFor Leaving: ______________________ Areas In Which You Drove: _______________
                                                                             Held: ________________________________ Satellite Communication: Yes
                                                                    Reason For Leaving: ______________________ Areas In Which You Drove: _______________             _                       No
Type of Equipment Driven: ____________________ Position Held: ________________________________ Satellite Communication: Yes
  ______________________________________ Position
From: Equipment Driven: ____________________ Reason Held: ________________________________ Satellite Communication:
         ______________ To: ______________                                                                                                                           _              Yes      No
                                                                                                                                                                                             No
Type of Equipment Driven: ____________________ Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
Type of     Month
Phone Number: (____     _) ____________________ SECOND Name:____________________________________________________________
                       Year                 Month       Year        Company LAST EMPLOYER
                                                                             LAST EMPLOYER
  ______________________________________ THIRD For Leaving: ______________________ Areas In Which You Drove:________________
                                                                    Reason For Leaving: ______________________ Areas In Which You Drove:________________
  ______________________________________ Reason For Leaving: ______________________ Areas In Which You Drove: _______________
  ______________________________________ Reason
From: ______________ To: ______________ Position Held: ________________________________ Satellite Communication:                                                     _              Yes      No
Type of subject to DOTYear
Were youEquipment Driven: ____________________ THIRD LAST o No
            Month
            Month       regulations while working for this employer? o LAST EMPLOYER
                       Year                 Month
                                            Month       Year
                                                        Year        Address: Yes
                                                                    CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
                                                                    Company Name:____________________________________________________________
                                                                               Name:____________________________________________________________
Phone Number: (____                                                                    EMPLOYER
                        _) ____________________ THIRD For Leaving: ______________________ Areas In Which You Drove: _______________
  ______________________________________ SECOND LAST EMPLOYER
From: ______________ To: ______________ Reason Held: ________________________________
Were you required to perform safety sensitive functions (such as driving) subject to DOT drug and alcohol testing? o Yes o No Satellite Communication:
                                                                    Position
                                                                                                                                                                     _
                                                                                                                                                                                    Yes      No
Type of Equipment Driven: ____________________ Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
            Month      Year                 Month       Year        Address: Name:____________________________________________________________
                                                                    CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
Phone Number: (____     _) ____________________ THIRD LAST EMPLOYER Company Name:____________________________________________________________
  ______________________________________ Reason Held: ________________________________ Satellite Communication:
From: Equipment Driven: ____________________ PositionFor Leaving: ______________________ Areas In Which _______________ Zip ____________________
Type of ______________ To: ______________ Position Held: ________________________________ Satellite Communication:
                                                                                                                                                                     _
                                                                                                                                                          You Drove: _______________Yes
                                                                                                                                                                                    Yes      No
                                                                                                                                                                                             No
            Month      Year                 Month       Year        Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
                                                                              Street_____________________________________ City ____________________ State
                                                                    Company Name:____________________________________________________________
Phone Number: (____
Phone Number: (____     _) ____________________                              LAST EMPLOYER
                        _) ____________________ THIRD For Leaving: ______________________ Areas In Which You Drove:________________
                                                                    Reason For Leaving: ______________________ Areas In Which You Drove: _______________
From: Equipment Driven: ____________________ Reason Held: ________________________________ Satellite Communication:
  ______________________________________ Position                                                                                                                    _
                                                                                                                                                Satellite Communication:
         ______________ To: ______________ Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
Type of Equipment Driven: ____________________ Position Held: ________________________________
                                                                                                                                                                                    Yes
                                                                                                                                                                                    Yes      No
                                                                                                                                                                                             No
Type ofNumber: (____
Phone       Month      Year                 Month       Year       FOURTH Name:____________________________________________________________
                                                                    Company LAST EMPLOYER
                        _) ____________________ THIRD For Leaving: ______________________ Areas In Which You Drove: _______________
                                                                             LAST EMPLOYER
  ______________________________________ Reason Held: ________________________________ Satellite Communication:                                                      _
From: Equipment Driven: ____________________ Reason For Leaving: ______________________ Areas In Which _______________ Zip ____________________
Type of ______________ To: ______________ CompanyStreet_____________________________________ City ____________________ State You Drove: _______________              _
  ______________________________________ Position Name:____________________________________________________________                                                                 Yes      No
            Month      Year                 Month       Year        Address:
            Month
Phone Number: (____     _) ____________________ FOURTH LAST EMPLOYER
                       Year                 Month       Year        Company Name:____________________________________________________________
                                                                             LAST EMPLOYER
                                                                   THIRD For Leaving: ______________________ Areas In Which You Drove: _______________
  ______________________________________ Reason LAST EMPLOYER
From: ______________ To: ______________ FOURTHStreet_____________________________________ City ____________________ State _______________ Zip ____________________
From: ______________ To: ______________ Position Held: ________________________________ Satellite Communication:
                                                                                                                                                                     _
                                                                                                                                                                                    Yes      No
Type of subject to DOTYear ____________________ Address: Yes o No   Address:
Were youEquipment Driven: ____________________
            Month
Phone Number: (____
            Month (____ regulations while working for this employer? o Street_____________________________________ City ____________________ State _______________ Zip ____________________
                                            Month
                                            Month       Year
                        _) ____________________ FOURTH LAST EMPLOYER
                       Year                             Year        Company Name:____________________________________________________________
                        _)
Phone Number: to perform safety sensitive functions (such as driving) subject Leaving: ______________________ Areas In Which You Drove: _______________
From: Equipment Driven: ____________________ CompanyStreet_____________________________________ o ____________________ State _______________ Zip ____________________
  ______________________________________ Reason For to ________________________________ Satellite Communication:
            Month
Were you required      Year
         ______________ To: ______________
                                            Month       Year                   Name:____________________________________________________________
Type of Equipment Driven: ____________________ Position Held: ________________________________ Satellite Communication:
                                                                                                                                Yes o No
From: ______________ To: ______________ Position Held: DOT drug and alcohol testing? City ____________________ State _______________ Zip ____________________
                                                                                                                                                                     _              Yes
                                                                                                                                                                                    Yes      No
                                                                                                                                                                                             No
Type of ______________ To: ______________ Address: Street_____________________________________ City
From: Number: (____
            Month      Year                 Month       Year        Company Name:____________________________________________________________
Phone Number: (____     _) ____________________ FOURTHStreet_____________________________________ City ____________________ State _______________ Zip ____________________
                                                                                LAST EMPLOYER
  ______________________________________ Address:For Leaving: ______________________ Areas In Which You Drove: _______________
Phone                   _) ____________________                     Reason
  ______________________________________ Reason For Leaving: ______________________ Areas In Which You Drove: _______________
Phone Equipment Driven: ____________________ Position Held: ________________________________ Satellite Communication: Yes
From: Number: (____
         ______________ To: ______________
                        _)
                                                                                                                                                                     _
                                                                                                                                                                     _                       No
Type of Equipment Driven: ____________________ Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
Type of     Month
Phone Number: (____    Year                 Month       Year       FIFTH LAST EMPLOYER
                        _) ____________________ FOURTH LAST EMPLOYERCompany Name:____________________________________________________________
                                                                    PositionFor Leaving: ______________________ Areas In Which You Drove:________________
                                                                             Held: ________________________________ Satellite Communication: Yes                                             No
Type of Equipment Driven: ____________________ Reason Held: ________________________________ Satellite Communication: Yes
  ______________________________________
  ______________________________________
From: Equipment Driven: ____________________ Position Street_____________________________________ City ____________________ State _______________ Zip ____________________                   No
Type of ______________ To: ______________ Address: Name:____________________________________________________________
            Month      Year                 Month       Year        Company Leaving: ______________________ Areas In Which You Drove: _______________
  ______________________________________ FIFTH LAST EMPLOYER
            Month
Phone Number: (____     _) ____________________ FOURTH Name:____________________________________________________________
                       Year                 Month       Year        Reason For
                                                                    Company LAST EMPLOYER                                                                            _
From: ______________ To: ______________ Reason For Leaving: ______________________ Areas In Which You Drove: _______________
  ______________________________________
From: Equipment Driven: ____________________ Position Held: ________________________________ Satellite Communication:
                                                                                                                                                                     _
                                                                                                                                                                                    Yes      No
Type of ______________ To: ______________ FIFTH LAST EMPLOYER
            Month      Year                 Month       Year
                                                                    Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
                                                                    Address: Name:____________________________________________________________
                                                                    CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
            Month (____
Phone Number: (____
Phone Number:           _) ____________________ FIFTH LAST EMPLOYER
                       Year                 Month
                        _) ____________________
                                                        Year
From: Equipment Driven: ____________________ Reason For Leaving: ______________________ Areas In Which You Drove: _______________
  ______________________________________ Position
From: ______________ To: ______________ Position Held: ________________________________ Satellite Communication:
Type of ______________ To: ______________ Address: Held: ________________________________ Satellite Communication:
                                                                                                                                                                     _              Yes
                                                                                                                                                                                    Yes      No
                                                                                                                                                                                             No
Type of subject to DOTYear ____________________ CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
            Month
            Month
                                            Month
Were youEquipment Driven: ____________________          Year
                        regulations while working for this employer? o Yes o No
                       Year                 Month       Year                   Name:____________________________________________________________
                                                                               Name:____________________________________________________________
                                                                    CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
Phone Number: (____
Phone Number: (____     _) ____________________ FIFTH LAST EMPLOYER
                        _)                                          Reason For Leaving: ______________________ Areas In Which You Drove: _______________
  ______________________________________ driving) subject Leaving: ______________________ Areas In Which You Drove: _______________                                  _
From: ______________ To: ______________ Reason Held: ________________________________
Were you required to perform safety sensitive functions (such as PositionFor to DOT drug and alcohol testing? o Yes o No Satellite Communication:
  ______________________________________
         ______________ To: ______________                                                                                                                           _
From: Equipment Driven: ____________________ Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________          Yes      No
Type of Equipment Driven: ____________________ Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
Type of     Month
Phone Number: (____     _) ____________________ SIXTH LAST EMPLOYER
                       Year                 Month       Year        Company Name:____________________________________________________________
  ______________________________________ FIFTH LAST EMPLOYER
  ______________________________________ Reason For Leaving: ______________________ Areas In Which You Drove: _______________
From: ______________ To: ______________ Position Held: ________________________________ Satellite Communication:
                                                                                                                                                                     _
                                                                                                                                                                                    Yes      No
Type of Equipment Driven: ____________________ CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
            Month
            Month
                       Year
                       Year
                                            Month
                                            Month
                                                        Year
                                                        Year
                                                                    Address: Name:____________________________________________________________
                                                                    Company Name:____________________________________________________________
                                                                   SIXTH LAST EMPLOYER
From: ______________ To: ______________ FIFTH For Leaving: ______________________ Areas In Which You Drove: _______________
Phone Number: (____     _) ____________________
  ______________________________________ Reason For Leaving: ______________________ Areas In Which You Drove:________________
  ______________________________________ Position
From: Equipment Driven: ____________________ Reason Held: ________________________________ Satellite Communication:
                                                                                                                                                                     _
Type of ______________ To: ______________ Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
            Month      Year                 Month       Year        Address: Name:____________________________________________________________
                                                                                                                                                                                    Yes      No
                                                                    CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
Phone Number: (____
            Month
Phone Number: (____     _) ____________________ SIXTH LAST EMPLOYER
                       Year                 Month       Year
                        _) ____________________ SIXTH LAST EMPLOYER
From: Equipment Driven: ____________________ PositionFor Leaving: ______________________ Areas In Which You Drove: _______________
From: ______________ To: ______________ Reason Held: ________________________________ Satellite Communication:
  ______________________________________
Type of Equipment Driven: ____________________ Position Held: ________________________________ Satellite Communication:
                                                                                                                                                                     _
         ______________ To: ______________ Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________            Yes
                                                                                                                                                                                    Yes      No
                                                                                                                                                                                             No
Type of     Month      Year                 Month       Year                   Name:____________________________________________________________
                                                                    CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
Phone Number: (____
Phone Number: (____     _) ____________________ SIXTH LAST EMPLOYER
                        _)
                       Year ____________________
  ______________________________________ Company Name:____________________________________________________________
            Month                           Month       Year        Reason For Leaving: ______________________ Areas In Which You Drove: _______________             ________________
From: Equipment Driven: ____________________ Reason For Leaving: ______________________ Areas In Which You Drove:
  ______________________________________
Type of ______________ To: ______________ Position Held: ________________________________ Satellite Communication:
                                                                                                                                                                     _              Yes      No
From: subject to DOTYear ____________________ Address: YesLAST EMPLOYER
Type of ______________ To: ______________ CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
Were youEquipment Driven: ____________________ SEVENTHName:____________________________________________________________
            Month                                                                     o No
                        regulations while working for this employer? o Street_____________________________________ City ____________________ State _______________ Zip ____________________
                                            Month       Year
Phone Number: (____     _)
  ______________________________________ Reason                     Address:For Leaving: ______________________ Areas In Which You Drove:________________
                                                                   SIXTH LAST EMPLOYER
  ______________________________________
Phone Number: to perform safety sensitive functions (such as driving) subject to DOT drug and alcohol testing? o Yes o No Satellite Communication: Yes
From: Equipment Driven: ____________________
Were you required(____  _) ____________________
Type of ______________ To: ______________ Position Held: ________________________________
            Month      Year                 Month       Year        Address: Name:____________________________________________________________
                                                                                                                                                                                             No
                                                                    CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
Phone Equipment Driven: ____________________ SEVENTHName:____________________________________________________________
            Month
Type ofNumber: (____
                       Year                 Month       Year
                        _) ____________________ SIXTH LAST EMPLOYER Position Held: ________________________________ Satellite Communication: Yes
                                                                    Company LAST EMPLOYER                                                                                                    No
  ______________________________________
From: ______________ To: ______________ Reason For Leaving: ______________________ Areas In Which You Drove: _______________
From: Equipment Driven: ____________________ Position Held: ________________________________ Satellite Communication:                                                _
         ______________ To: ______________ Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
Type of                                                                                                                                                                             Yes      No
  ______________________________________ Address:For Leaving: ______________________ Areas In Which _______________ Zip ____________________
            Month
Phone Number: (____
            Month       _) ____________________ SEVENTHName:____________________________________________________________
                       Year
                       Year                 Month
                                            Month       Year
                                                        Year        Reason Street_____________________________________ City ____________________ State You Drove:________________
                                                                    Company LAST EMPLOYER
Phone Number: (____     _) ____________________
  ______________________________________ Position Held: ________________________________ Satellite Communication:
From: Equipment Driven: ____________________ Reason For Leaving: ______________________ Areas In Which You Drove: _______________
         ______________ To: ______________ Position Held: ________________________________ Satellite Communication:
Type of Equipment Driven: ____________________ SEVENTH LAST EMPLOYER
                                                                                                                                                                     _              Yes
                                                                                                                                                                                    Yes      No
                                                                                                                                                                                             No
Type of                                                             Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
            Month
Phone Number: (____    Year                 Month       Year                   Name:____________________________________________________________
                                                                    CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
                        _) ____________________ SEVENTH LAST EMPLOYER
  ______________________________________
  ______________________________________ Reason For Leaving: ______________________ Areas In Which You Drove: _______________                                        _
From: Equipment Driven: ____________________ Reason For Leaving: ______________________ Areas In Which You Drove: _______________
Type of ______________ To: ______________ Position Held: ________________________________ Satellite Communication:
                                                                                                                                                                     _              Yes      No
            Month      Year                 Month       Year
                                                                    Address: Name:____________________________________________________________
                                                                    CompanyStreet_____________________________________ City ____________________ State _______________ Zip ____________________
            Month
Phone Number: (____    Year                 Month       Year        Company Name:____________________________________________________________
                        _) ____________________ SEVENTH LAST EMPLOYER
                          Use To: ______________ Position Street_____________________________________ City ____________________ State _______________ Zip ____________________
From: ______________ separate sheets for additional ______________________ Areas In Which You Drove:________________
From: ______________ To: ______________ Reason For Leaving: employment history, if necessary.
  ______________________________________
Type of subject to DOTYear ____________________ Address: Held: o No
Were youEquipment Driven: ____________________
                                                                                       ________________________________ Satellite Communication:                                    Yes      No
                                                                    Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________
Phone Number: (____regulations while working for this employer? o YesLAST EMPLOYER
            Month
Phone Number: (____     _) ____________________ SEVENTHName:____________________________________________________________
                        _)                  Month       Year        Company
From: Equipment Driven: ____________________ driving) subject Leaving: employment history, if necessary. _
                          Use separate sheets
Were youEquipment perform safety sensitive functions (such as for additional ______________________ Areas In Which You Drove: _______________
  ______________________________________ Reason For to ________________________________ Satellite Communication:
Type of required to Driven: ____________________ Position Held: DOTRevision 3, 4/09 testing? o ____________________ State _______________ Zip ____________________3
                                                                                            drug and alcohol                    Yes o No                                            Yes      No
Type of ______________ To: ______________ Position Held: ________________________________ Satellite Communication:
                                                                               Version 3,
                                                                    Address: Street_____________________________________ City
                                                                                                                                                                                    Yes      No
            Month
Phone Number: (____
                       Year                 Month
                        _) ____________________
                                                        Year        Company Name:____________________________________________________________
  ______________________________________ Reason For Leaving: employment history, if necessary. _
From: ______________ separate sheets for additional ______________________ Areas In Which You Drove: _______________
                          Use To: ______________ Address: Street_____________________________________ City ____________________ State _______________ Zip ____________________3
Type of Equipment Driven: ____________________ Position Held: ________________________________ Satellite Communication:
                                                                               Version 3, Revision 3, 4/09                                                                          Yes      No
Phone Number: (____     _) ____________________
                          Use separate sheets Position Held: ________________________________ Satellite Communication: Yes No 3
Type of Equipment Driven: ____________________ for additional employment history, if necessary.
  ______________________________________ Reason For Leaving: ______________________ Areas In Which You Drove: _______________                                        _
                                                                               Version 3, Revision 3, 4/09
  ______________________________________
                  Use separate sheets                                 Reason For Leaving: employment history, if necessary.
                                                                    for additional ______________________ Areas In Which You Drove:________________ 3
                                                                               Version 3, Revision 3, 4/09
                                                                                   Version 3, Revision 4, 7 /1 0                                                                                3
                            Use separate sheets for additional employment history, if necessary.
                                                        Version 3, Revision 3, 4/09                                                                                                             3
                                                                 GENERAL DRIVING RECORD
To date, I have driven trucks for _____________ years, covering approximately_________miles.
                                                                             /        /
The date of my last accident while driving a commercial vehicle was__________________________.
                                                                                            Month                Date         Year
Since that time, I have driven approximately ___________________________ accident free miles.
During the last three years, I have driven regularly in the following states: ______________________________________________

                                                                    SAFE DRIVING AWARDS, ETC.
          Date                       Kind of Award                           Presented By                      While Employed By                   In Recognition Of




                                                                    EDUCATION / TRAINING
List driver training courses or driving schools attended:                                School Name: _____________ School Start Date: _______________
                                                                                                                                            /    /
Address of School:__________________________________________________________ Graduation Date: _______________
                                                                                                    /   /
         Can you read English? Yes   No     Speak English? Yes   No    Write English?   Yes      No
                                 DRIVERS LICENSE: LIST ALL DRIVERS LICENSES HELD IN PAST SEVEN YEARS
          State                     License Number                                Class                           Endorsements                       Expiration Date




            If you have held a drivers license in any other name within the last 10 years, please provide the other name(s):
                                                                                                                    ___________
Last ________________________________________________________________________________ First ___________________________________ Middle __________________________


          TRAFFIC CONVICTIONS AND FORFEITURES, OTHER THAN PARKING VIOLATIONS: LIST FOR PAST THREE YEARS
               Includes On-Duty or Off-Duty and while in either a commercial or personal vehicle. If none, must write “NONE.”
          Date                    City/State                          Charge — if speeding, how fast?                    Penalty




                                                                             ACCIDENT RECORD
                    List all accidents within the past three years regardless of whether it involved a commercial or personal vehicle.
            Include preventable and non-preventable accidents and any that involved property damage. If none, must write “NONE.”
                                                                                      LE

                                                                                     LE
                                                                             ERI OUS
                                                                        AB

                                                                                 TAB

                                                                                 AL
                                                                    E NT



                                                                         MAT ARD
                                                                             VEN




   Date           Type of        Nature of Accident                                         Fatalities        Injuries      Amount of            City/State          Employer
                                                                         PREN-
                                                                     V



                                                                          HAZ




                  Vehicle     (Head on, Rear-end, Etc.)                                                                  Property Damage
                                                                 PRE

                                                                          NO




                                                                                            Yes / No          Yes / No




List 3 Personal References (other than relatives or past employers):
Name ______________________________________Address ____________________________________________________Occupation ________________________________Phone (______) ____________________

Name ______________________________________Address ____________________________________________________Occupation ________________________________Phone (______) ____________________

Name ______________________________________Address ____________________________________________________Occupation ________________________________Phone (______) ____________________

List any addresses you have maintained during the past three years other than your present address:
1. Street ________________________________________________ City ________________________________ State _______                            Zip ____________ How long?_______
2. Street ________________________________________________ City ________________________________ State _______                            Zip ____________ How long?_______
3. Street ________________________________________________ City ________________________________ State _______                            Zip ____________ How long?_______

                                                                              Version 3, Revision 4, 7 /1 0                                                                             4
                                                                Job Analysis
Position Title: Long Haul Semi-Tractor Driver Dictionary of Occupational Titles: 904.383-010
Department: Driver Services Reports to: Operations Classification: Exempt
                                                                                                                                    888.832.6484 (phone)
Job Summary:                                                                                                                         866.804.0715 (fax)
a. Position requires a Medical Examiners Certificate as required under Sub-part E, section 391
of the Federal Motor Carriers Safety Regulations.
NOTE: PERFORMANCE OF ALL WORK TASK AND JOB ACTIVITIES ARE SUBJECT TO HIGH ALTITUDE ENVIRONMENTS, FROM SEA
LEVEL TO ELEVATIONS GREATER THAN OF 10000 FEET.
b. Position requires the physical demand(s) of continuous sitting for periods up to 10 hours, in the seat and cab of a tractor
(truck) during various weather and altitude (mountain elevations) driving conditions.
c. Position requires the physical demand(s) of occasional walking, kneeling, squatting, stooping, reaching, grasping,
pushing, pulling, and climbing, as necessary to enter/exit a truck cab and trailer cargo area and perform equipment
inspections as required under Part 396 of the Federal Motor Carrier Safety Regulations.
d. Position requires the physical demand(s) of occasional walking, bending, crouching, reaching, grasping, rotating or lifting,
pulling and pushing wheeled equipment with tongue weight(s) up to 128 pounds, a distance of 1 – 5 feet, as required to
perform the essential function(s) of coupling or uncoupling multiple trailer combinations.
e. Position requires the physical demand(s) of occasional walking, standing, bending, crouching, squatting, grasping, reaching,
rotating and lifting/carrying up to 75 pounds a distance of 1 – 53 feet. This may also include lifting above the shoulder and
head level. The essential function(s), include, but are not limited to, monitoring loading and unloading activity, handling and
securing cargo or installing safety devices (tire chains) as required by the Federal Motor Carriers Safety Regulations.
f. Position requires the physical demand of wrist pronation and supination as necessary to operate commercial motor vehicle controls.
g. Position is subject loading/unloading packaged fiberglass or insulation cargo.
Equipment / Tools:
          Equipment – Tractor-Trailer, tractor controls, fifth-wheel and trailer slider release, trailer landing-gear, congear (dolly),
          hand-truck, forklift, manual and power pallet-jack, freight cart, load locks, chain(s).
          Tools - fifth-wheel and trailer-slider pull tool(s), hand tool(s), rope, computer keyboard, pen, map(s), calculator, logbook.
Work Environment:
          Position is subject to irregular work schedules, occasional temperature and weather extremes, long trips, short notice
          for trip assignments, tight delivery schedules, delays enroute and other stresses and fatigue related to driving a large
          commercial motor vehicle on crowed streets and highways.
Noise intensity level(s) is mild, which are normal decibels for outdoor or indoor work.
Performance Dimensions and Essential Task: This job analysis group essential functions and task by domain. The following
scale defines percentage of workday for each domain as occasional, frequently and continuously and indicates the limits of
weight(s) lifted/carried or force exerted (in pounds).

                                    Rating                Occasional                           Frequently             Constantly

                            % of WORK DAY                 1-33%                                  34-66%               67-100%

                            Sedentary                      0-10 lbs.                             0                    0

                            Light                          0-20 lbs.                             0-10 lbs.            0

                            Medium                         20-50 lbs.                            10-25 lbs.           1-10 lbs.

                            Heavy                          50-100 lbs.                           25-50 lbs.           10-20 lbs.

                            Very Heavy                     128 lbs.*                             50 lbs.              20 lbs.
                          The Long Haul Semi-Tractor Driver Job is defined as HEAVY for STRENGTH
                          *Doubles



                                                         PHYSICAL REQUIREMENTS
 Do you have a current D.O.T. physical certificate?           Yes             No         If yes, please provide the following:
 Name of Doctor_________________________________ Address _________________________________________________ Exam Date ________________ Expires _______________

 All driver candidates seeking employment with Gordon Trucking, Inc. must be physically able to perform the essential job
 functions listed in the driver’s job analysis.
 ARE YOU ABLE TO:
 Complete written logs and written time sheets?                                               YES             NO
 Physically conduct pre-trip inspections of a tractor and trailer?                            YES             NO
 Physically make and break double trailers? *                                                 YES             NO   * If doubles certified
 NOTE: Please do NOT submit any medical information. We will not be able to process any application accompanied by
 unsolicited medical information.


                                                                       Version 3, Revision 4, 7 /1 0                                                            5
NOTICE, AUTHORIZATION AND RELEASE FOR PRE-EMPLOYMENT INQUIRIES
I understand that as condition of processing my application for employment, Gordon Trucking, Inc is requiring that I authorize Gordon Trucking, Inc. or its
designees to conduct certain pre-employment inquiries. I understand that, prior to signing this Notice, Authorization and Release, I have the right to end the
application process and not submit to the items set forth below.
Authorization to Release Work Records, Others Records and Drug and Alcohol Test results: I hereby authorize, without liability, any person, including
but not limited to previous employers, education Institutions, third party agencies selected by Gordon trucking Inc. to received information, or any other
institution to furnish Gordon Trucking, Inc. information relating to any accidents in which I was involved in addition to any information they may have
concerning my character, habits, ability, financial responsibility, job performance, and reasons for leaving employment. I further authorize any law
enforcement agency or court of record to furnish Gordon Trucking, Inc. information concerning my motor vehicle record, or any felony or misdemeanor of
which I have been convicted. I hereby release all such persons and organizations from any claims for damages of any kind which may occur to me as a
result of furnishing such information. In addition, I hereby authorize Gordon Trucking, Inc. to obtain form my prior employers during the three (3) year period
preceding the date of application, information about me regarding Alcohol test with a concentration result of 0.04 or greater, positive drug test results,
refusals to be tested (Including verified adulterated or substituted drug test results), other violations of Federal Motor Carriers Safety Administration drug or
alcohol regulations and, if applicable, completion of return-to-duty requirements following violation of a D.O.T. drug or alcohol regulation. I hereby authorize
and consent to the release of this information by my prior employers Gordon Trucking, Inc. in person, by telephone, in writing or by other method of
transmission ensuring confidentiality.
Consumer Reports: I understand that a criminal conviction will not necessarily bar me from employment unless such conviction relates to unsuitability for
the position of which you are applying. I understand that a consumer report(s) and/or investigative consumer report(s) maybe be obtained in connection with
my application for and/or throughout my continued employment with Gordon Trucking, Inc. These reports may contain the following types of information:
employment history, motor vehicle record, criminal conviction record, character, general reputation, personal characteristics, mode of living and/or credit and
indebtedness collected from federal, state, and other agencies that maintain such records; as well as information from any third party agency deemed
appropriate by Gordon Trucking, Inc. concerning previous driving record requests made by others from such state agencies and state provided driving
records. For the most part, the information contained in the report will be obtained from public record and private commercial sources; however Gordon
Trucking, Inc. may obtain information, as appropriate, from other private sources such as personal interviews with neighbors, friends & associates.
Drug and Alcohol Testing: I understand that in the event that I am given a conditional offer of employment (or any offer of contact for services) I
understand that, pursuant to federal and state law, I will be required to undergo alcohol and drug testing. I understand that I will be required to provide urine,
hair or other biological samples to be tested for the presences for controlled substances. If employed or contracted, I will be required to submit to drug
and/or alcohol test as required by Gordon Trucking, Inc.’s Controlled Substance and Alcohol Use and Testing Policy and/or federal or state regulations. In
the event of post-accident drug testing, I understand that any sample submitted for testing pursuant to Gordon Trucking, Inc. policy, shall become the
property of Gordon Trucking, Inc.
Pre-employment Full Medical Examination: I understand and agree that, in the event I am given a conditional offer of employment, Gordon Trucking, Inc.
may condition acceptance of that offer on my satisfactory completion of Gordon Trucking, Inc. full medical examination. This examination will be conducted
by physicians chosen by Gordon Trucking, Inc. Satisfactory completion of the Medical Examination means obtaining a D.O.T. Medical Examiners
Certification, good for one year, full disclosure of complete medical history, and a determination that I can perform the essential functions of the position of
Long Haul Semi Tractor Driver. I further understand, that as a part of this medical examination, follow-up inquires may be made, which may include
obtaining and reviewing prior medical records and/or worker’s compensations records. I understand that providing false, misleading, or incomplete
information during this or any medical examination may be grounds for disqualification or, if employed, termination of employment.
**IMPORTANT NOTICE REGARDING BACKGROUND REPORTS OBTAINED FROM PSP ONLINE SERVICE. In connection with your application for
employment with Gordon Trucking, Inc. (“Prospective Employer”), Prospective Employer may obtain one or more reports regarding your driving, and safety
inspection history from the Federal Motor Carrier Safety Administration (FMCSA). 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
FMCSA report upon which its decision was based. To obtain the FMCSA report, along with a brief acknowledgement of whether the information contained
in the FMCSA report affected the Prospective Employer’s hiring decision, you must submit a written request for a copy of the report to Scott Manthey, VP-
Safety and Compliance. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. Your signature at the
bottom of this document signifies that you agree to allow the Prospective Employer to access the FMCSA Pre-Employment Screening Program (PSP)
system to seek information regarding your commercial driving safety record and information regarding your safety inspection history. You also understand
and agree that you are consenting to the release of safety performance information including crash data from the previous five (5) years and inspection
history from the previous three (3) years. You further understand and acknowledge that this release of information may assist the Prospective Employer to
make a determination regarding your suitability as an employee. You 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. You may challenge the accuracy of the
data by submitting a request to https://dataqs.fmcsa.dot.gov. If you are challenging 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. You have read the above Notice
Regarding Background Reports provided to you by Prospective Employer and you understand that if you sign this consent form, Prospective Employer may
obtain a report of your crash and inspection history. Your signature below hereby authorizes Prospective Employer and its employees, authorized agents,
and/or affiliates to obtain the information authorized above.

Application Rights: I have the right to make a request to any third party agency deemed appropriate by Gordon Trucking, Inc. upon proper identification, to
request the nature of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me
which any third party agency deemed appropriate by Gordon Trucking, Inc. has previously furnished within a two year period preceding my request. I also
understand that I have the right to review information provided by previous employers, to have any errors in the information corrected by previous employers
and for those previous employers to re-send the corrected information to Gordon Trucking, Inc. and to have a rebuttal statement attached if the previous
employer and I cannot agree on the accuracy of the information.
If hired (or contracted), I understand that periodic consumer reports may be ran pursuant to company policy and this authorization shall remain on file and
shall serve as a n ongoing authorization for you to procure consumer reports at any time during my employment or (contact) period. I also understand that
before any adverse action is taken, based in whole of in part on the information contained in the consumer report, you will be provided a copy of the report,
the name, address, and telephone number of the reporting agency, a summary of your rights under the federal and, where applicable, such California or
Washington, state Fair Credit Reporting Acts, as well as additional information on rights under the applicable laws.
_______ (INITIAL) 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. Any false, misleading, or incomplete statement to the information requested in this application or on D.O.T. physical shall be sufficient
grounds for denial of employment or if hired or contracted, discharge from employment. Any offers of employment will be conditioned upon successfully
completing D.O.T. physical and company screening, drug screen, criminal background check and company road test.
________________________________             ________________________________                       ________________________________   ____________________
      Applicant’s Name (Print)                           Signature                                          Social Security No.             Date of Birth
                                                                    Version 3, Revision 4, 7 /1 0                                                                6
REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER
REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER
 I hereby authorize you to release the following information to GORDON TRUCKING, INC.
 for purposes of investigation as required by Section 391.23 of the Federal Motor Carrier
 Safety Regulations. You release the following information to GORDON TRUCKING, INC.
 I hereby authorize you toare released from any and all liability that may result from furnishing 888.832.6484 (phone)
 for purposes of investigation as required by Section 391.23 of the Federal Motor Carrier
 such information.
                                                                                                   866.804.0715 (fax)
                                                                                                  888.832.6484 (phone)
 Safety Regulations. You are released from any and all liability that may result from furnishing   866.804.0715 (fax)
 I hereby authorize my previous employer to release and forward all information on my Alcohol and Controlled
 such information.
 Substances Testing/Training records and any other records requested to GORDON TRUCKING, INC. in compliance
 I hereby authorize (f previous employer to release and forward
 with Section 382.405my through h) and Section 382.413 (a through g). all information on my Alcohol and Controlled
 Substances Testing/Training records and any other records requested to GORDON TRUCKING, INC. in compliance
        SS # 382.405 (f through h) and Section 382.413 (a through g).
 with Section_________________________                             X_____________________________________
                                                                                                    (print full name)
         SS # _________________________
              _________________________                                              X_____________________________________
                                                                                     X_____________________________________
                                                                                                    (print full name)
REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER signature)
              (date)                      (applicant’s
              _________________________                          X_____________________________________
                           (date)                                                 (applicant’s signature)
**********APPLICANT - DO NOT COMPLETE ANYTHING BELOW THIS LINE**********
  I hereby authorize you to release the following information to GORDON TRUCKING, INC.
Dear purposes of investigation as required COMPLETE ANYTHING Motor Carrier
  for Sir/Madam:
**********APPLICANT - DO NOTby Section 391.23 of the Federal BELOW THIS LINE**********                    888.832.6484 (phone)
  Safety Regulations. You are has applied to GORDON TRUCKING, INC. for a position as
The below named individual released from any and all liability that may result from furnishinga DRIVER and states that
Dear Sir/Madam:                                                                                            866.804.0715 (fax)
  such information.
he/she was employed by ______________________________________ as _____________________________________
The below named individual has applied to GORDON TRUCKING, INC. for a position as a DRIVER and states that
                                          COMPANY release
  I hereby authorize my previous employer to NAME and forward all information on my Alcohol and Controlled
he/she was employed by ______________________________________ as _____________________________________
  Substances Testing/Training records and any other records requested to GORDON TRUCKING, INC. in compliance
from                               to     COMPANY NAME             .
  with                              h)
Name Section 382.405 (f through to and Section 382.413 (a through. g). Security #
from of Applicant                                                Social
                                                                 Social Security below.
We appreciate your time in completing, in confidence, the information requested #
Name ofSS # _________________________
          Applicant                                              X_____________________________________
                                                                                     (print
Sincerely, GORDON TRUCKING, INC. confidence, the information requested below. full name)
We appreciate your time in completing, in
              _________________________                          X_____________________________________
Sincerely, GORDON TRUCKING, INC.
1. Employed from           (date) to             as                              (OTR / REGIONAL/LOCAL DRIVER)
                                                                                  (applicant’s signature)

1. Employed from a commercialDO NOT COMPLETE ANYTHING BELOW THIS LINE**********
2. Did he/she drive
**********APPLICANT -tovehicle for you?          as                              (OTR / REGIONAL/LOCAL DRIVER)
                               Tractor/Semi-Trailer?
   Straight Truck? a commercial vehicle for you?
2. Did he/she drive                                             Bus?                     Other? (Specify)
Dear Sir/Madam:
   Straight Truck?             Tractor/Semi-Trailer?            Bus?                     Other? (Specify)
3. Was he/she a safe and efficient driver?
The below named individual has applied to GORDON TRUCKING, INC. for a position as a DRIVER and states that
3. Was he/she a safe and efficient driver?
   Reason employed your company: Discharged                       Resignation                     Lay Off
he/she was for leavingby ______________________________________ as _____________________________________
                                Explain COMPANY
                                         (if Necessary):
Military Duty leaving your company: Discharged NAME
3. Reason for                                                     Resignation                     Lay Off
from his/her
4. Was                            to
                                Explain (if
Military Duty general conduct satisfactory? Necessary):            .
                                                                Eligible for Rehire?
Name of Applicant                                               Social Security #
Please his/her general conduct satisfactory?
4. Was indicate your opinion by placing an X in the appropriate column: Rehire?
                                                                Eligible for
We appreciate your time in completing, in confidence, the information requested below.
Please indicate your opinion by placing an X in the appropriate column:
   CHARACTERISTICS
Sincerely, GORDON TRUCKING, INC.                    EXCELLENT           GOOD               FAIR           POOR
   CHARACTERISTICS                                        EXCELLENT                     GOOD                  FAIR            POOR
    Employed Tact,
1. Disposition, from Ability to Get Along with Others
                                      to               as                                         (OTR / REGIONAL/LOCAL DRIVER)
2. Initiative Tact, Ability to Get Along with Others
   Disposition, drive a commercial vehicle for you?
    Did he/she
   Safety Habits
    Straight
   Initiative Truck?                Tractor/Semi-Trailer?                       Bus?                      Other? (Specify)
   Driving Skill
   Safety Habits safe and efficient driver?
3. Was he/she a
   Attitude
   Driving Skill
3. Reason for leaving your company: Discharged                                     Resignation                     Lay Off
   Attitude
 Other Remarks
Military Duty                         Explain (if Necessary):ACCIDENT RECORD
 Other this person ever tested satisfactory? list all accidents within the past three years.
                                                                                 in the past Rehire?
1. Hashis/her general conduct positive for a controlled substanceEligible forthree years?
4. Was Remarks                                 Please                                                                      YES          NO
2. Hasindicate your opinion by placing ancontrolledappropriate column: three threeIf none, please write “NONE.”
1.
Please   Include preventabletested positivewithaaccidents andsubstance in thein the past years?
          this person everan alcohol test for a X in the 0.04 or greater property damage. years?
                       had and non-preventable B.A.C. of any that involved past                                            YES
                                                                                                                           YES          NO
                                                                                                                                        NO
                       had refused a test with a B.A.C. of or alcohol in the past three years?
3. Has this person everan alcoholrequired test for drugs0.04 or greater in the past three years?
2.                                                                                                                         YES
                                                                                                                           YES          NO
                                                                                                                                        NO
                                                                        LE

                                                                       LE




                                                          EXCELLENT
   CHARACTERISTICS violations of D.O.T. agency Drug & Alcohol Regulations in the past three years?
                                                                                        GOOD                  FAIR            POOR NO
                                                                   IAL S
                                                          AB



                                                               TER OU




3. Has this person had other
4. Has this person ever refused a required test for drugs or alcohol in the past three years?                              YES
                                                                    TAB




                                                                                                                           YES          NO
                                                      E NT



                                                                 ARD
                                                                VEN




5. Has thisType of violated to D.O.T. drug D.O.T. agency Drug in the past Regulations
    Has this person Ability a Get Along with Others
              person
4. Disposition, Tact,had other violations of or alcohol regulation & Alcohol three years? in theAmount of years?
                            Nature of Accident
                                                                                                        past three         YES
                                                                                                                           YES          NO
                                                                                                                                        NO
                                                            PREN-
                                                        V



                                                             HAZ




                        (Head on, Rear-end, Etc.)
   a. If yes,Vehicle violated successfully completed follow-up and the past threeYes / No Property Damage
                                                    PRE




              has this person a D.O.T. drug or alcohol regulation in return to duty years? testing?
                                                             NO




                                                                             Yes / No
                                                            MA




5. Initiative person
    Has this                                                                                                               YES
                                                                                                                           YES          NO
                                                                                                                                        NO
            includes person successfully completed follow-up and return to duty testing?
     (ThisHabitsthisany information obtained from previous employers relating to drug or alcohol testing.)
   Safety has
   a. If yes,                                                                                                              YES          NO
* This includes all pre-employment testing.
     (This Skill                        obtained from previous employers relating to drug or
   Driving includes any informationabove questions, please give the SAP’s name, address,alcohol testing.)
If you includes all pre-employment testing.
* Thisanswered YES to any of the
   Attitude
                                                                                                     and phone number for further reference:
NAME
If you answered YES to any of the above questions, please give the SAP’s name, address, and phone number for further reference:
 Other Remarks
ADDRESS
NAME                                                                                                      ZIP
1. Has this person ever tested positive for a controlled substance in the past three years? ZIP
PHONE NUMBER
ADDRESS                                                                                                                    YES          NO
2. Has this person had an alcohol test with a B.A.C. of 0.04 or greater in the past three years?                           YES          NO
PHONE NUMBER
 SIGNATURE X
3. Has this person ever refused a required test for drugs or alcohol in the past three years?                              YES          NO
 SIGNATURE Xhad other violations of D.O.T. agency Drug & Alcohol Regulations in the past three years?
 Title this person
4. Has                                                                                             Date                    YES          NO
 Title
5. Has this person violated a D.O.T. drug or alcohol regulation in the past three years? Date
                                                           Version 3, Revision 3, 4/09                                     YES          NO     7
   a. If yes, has this person successfully completed follow-up and return to duty testing?
                                                           Version 3, Revision 3, 4/09                                     YES          NO     7
     (This includes any information obtained from previous employers relating to drug or alcohol testing.)
* This includes all pre-employment testing.
If you answered YES to any of the above questions, please give the SAP’s name, address, and phone number for further reference:
NAME
ADDRESS                                                                                                   ZIP
PHONE NUMBER
 SIGNATURE X
 Title                                                                                            Date
                                                               Version 3, Revision 4, 7 /1 0                                                   7

				
DOCUMENT INFO
Description: Driver Qualification Job Application document sample