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Independant Contractor Application document sample
Document Sample
Independent Contractor Application
Corporate Office Northern California Nevada Arizona
415 Lemon Avenue 3032 S. El Dorado Street 8000 W. Lake Mead Drive 702 N. 4th Street
P.O. Box 390 P.O. Box 6068 P.O. Box 90538 Buckeye, AZ 85326
Walnut, CA 91789 Stockton, CA 95206 Henderson, NV 89015 Ph# (623) 386-6860
Ph# (909) 594-2855 Ph# (209) 466-0481 Ph# (702) 565-5701 FAX (623) 386-7466
FAX (909) 595-9983 FAX (209) 465-8060 FAX (702) 565-6744
Nevada Oregon Arizona DTI Associates, LLC
21/2 miles east of Carlin 11619 N. Force Ave. 962 E. Highway 70 1628 Sportsman Drive
Nevada on old highway 40 Portland, OR 97217 P.O. Box 231 Compton, CA 90221
Ph# (775) 754-2562 Ph# (503) 283-5684 Safford, AZ 85546 Ph# (310) 635-9005
FAX (775) 754-2561 FAX (503) 283-5971 Ph# (928) 348-8858 Fax (310) 635-6376
FAX (928) 348-8868
WestCoast Bulk Transportation
17201 D Street (ANSWER ALL QUESTIONS – PLEASE PRINT CLEARLY)
Victorville, CA 92394
Ph# (760) 843-0774
Fax (760) 843-0775 Date of Application:
Social Security
or Federal ID No:
(Last) (First) (Middle)
Address:
Street City
State Zip Phone
How Long?
}
ADDRESS
FOR PAST (Street) (City) (State & Zip Code)
THREE How Long?
YEARS (Street) (City) (State & Zip Code)
Do you have the legal right to work in the United States?
Date of Birth Can you provide proof of age?
(Required for Truck Drivers)
Have you worked for this company before? Where?
Dates: From To Rate of Pay Position
Reason for leaving?
Are you now employed Or under contract? If not, how long since leaving last Job
Who referred you? Rate expected?
Emergency Contact: Phone No. Relationship:
Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job
Description]? YES NO
If yes, explain if you wish:
Company’s Initials: Date: Applicant’s Initials: Date:
File Name: Independent Contractor Application Rev10 Revision Date: 06/06/06 Page 1 of 4
This application will be held for thirty (30) days.
WORK HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all prior carriers that they were contracted to
during the preceding 3 years.
Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on
those carriers for whom the applicant operated such vehicle. (NOTE: List carriers in reverse order starting with the most recent. Add
another sheet as necessary.)
PRIOR CARRIERS DATE
From To
Name: Mo. Yr. Mo. Yr.
Position Held
Address:
Compensation
City: State: Zip:
Reason for Leaving
Contact Person: Phone Number:
PRIOR CARRIERS DATE
From To
Name: Mo. Yr. Mo. Yr.
Position Held
Address:
Compensation
City: State: Zip:
Reason for Leaving
Contact Person: Phone Number:
PRIOR CARRIERS DATE
From To
Name: Mo. Yr. Mo. Yr.
Position Held
Address:
Compensation
City: State: Zip:
Reason for Leaving
Contact Person: Phone Number:
PRIOR CARRIERS DATE
From To
Name: Mo. Yr. Mo. Yr.
Position Held
Address:
Compensation
City: State: Zip:
Reason for Leaving
Contact Person: Phone Number:
PRIOR CARRIERS DATE
From To
Name: Mo. Yr. Mo. Yr.
Position Held
Address:
Compensation
City: State: Zip:
Reason for Leaving
Contact Person: Phone Number:
PRIOR CARRIERS DATE
From To
Name: Mo. Yr. Mo. Yr.
Position Held
Address:
Compensation
City: State: Zip:
Reason for Leaving
Contact Person: Phone Number:
PRIOR CARRIERS DATE
From To
Name: Mo. Yr. Mo. Yr.
Position Held
Address:
Compensation
City: State: Zip:
Reason for Leaving
Contact Person: Phone Number:
'
Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to
transport hazardous materials in a quantity requiring placarding
Company’s Initials: Date: Applicant’s Initials: Date:
File Name: Independent Contractor Application Rev10 Revision Date: 06/06/06 Page 2 of 4
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED)
DATES NATURE OF ACCIDENT FATALITIES INJURIES
(HEAD-ON. REAR-ENO. UPSET. ETC.)
LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
LOCATION DATE CHARGE PENALTY
(ATTACH SHEET IF MORE SPACE IS NEEDED)
EDUCATION
CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4
LAST SCHOOL ATTENDED
(NAME) (CITY)
EXPERIENCE AND QUALIFICATIONS – DRIVER
STATE LICENSE NO. TYPE EXPIRATION DATE
DRIVER
LICENSE
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO
B. Has any license, permit or privilege ever been suspended or revoked? YES NO
IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS
DRIVING EXPERIENCE
TYPE OF EQUIPMENT DATES APPROX. NO OF MILES 1
CLASS OF EQUIPMENT
(VAN. TANK. FLAT. ETC. FROM TO (TOTAL)
LIST STATES OPERATED IN FOR LAST FIVE YEARS
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
Company’s Initials: Date: Applicant’s Initials: Date:
File Name: Independent Contractor Application Rev10 Revision Date: 06/06/06 Page 3 of 4
EXPERIENCE AND QUALIFICATIONS – OTHER
SHOW ANY TRUCKING. TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)
TO BE READ AND SIGNED BY APPLICANT
This certifies that this application was completed by me, and that all entries on it and information in it are
true and complete to the best of my knowledge.
I authorize you to make such investigations and inquiries of my personal, work, financial or medical history
and other related matters as may be necessary in arriving at a contract decision. (Generally, inquiries
regarding medical history will be made only if and after a conditional offer of a contract has been
extended.) I hereby release employers, schools, health care providers and other persons from all liability
in responding to inquiries and releasing information in connection with my application.
In the event of a contract, I understand that false or misleading information given in my application or
interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and
regulations of the Company.
In connection with my application for contract for services with you, I understand that a consumer report which may
contain public record information is being requested from DAC Services, Tulsa, Oklahoma. This report may include
the following types of information: names and dates of previous carriers, reason for termination of lease, work
experience, accidents, etc. I further understand that such report may contain public record information concerning
my driving record, worker's compensation claims, credit, bankruptcy proceedings, etc. from federal, state and other
agencies which maintain such records as well as information from DAC concerning (1) previous driving record
requests made by others from such state agencies; (2) state provided driving record; (3) claims involving me in the
files of insurance companies.
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY DAC TO FURNISH THE
ABOVE-MENTIONED INFORMATION.
I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all
information in its files on me at the time of my request; the sources of information; the recipients of any reports on
me which DAC has previously furnished within the two year period preceding my request. I hereby consent to your
obtaining the above information from DAC, and I agree that such information which DAC has or obtains, and my
employment history with you if I am hired, will be supplied by DAC to other companies which subscribe to DAC
Services.
Applicant's Signature Date
Company’s Initials: Date: Applicant’s Initials: Date:
File Name: Independent Contractor Application Rev10 Revision Date: 06/06/06 Page 4 of 4
Bulk Transportation WestCoast Bulk Transportation DTI
INFORMATION RELEASE AUTHORIZATION
I, ____________________________, do herein and hereby specifically authorize the Company to
investigate any and all information contained in my Application For Contract Work and any related
documents which include, but are not limited to, previous Carriers, references, medical records,
controlled substance abuse test results, breath alcohol test results, credit bureaus, or any other
sources deemed relevant by the Company in determining my suitability as an Independent
Contractor, whether specifically listed on my application or developed through investigation.
I clearly understand that pursuant to the Federal Motor Carrier Safety Regulations, Part 391.23, the
Company is required to request from previous Carriers any and all information relative to my
performance and qualifications as a driver. Therefore, I specifically authorize the release of such
information by any and all previous Carriers.
I clearly understand that pursuant to the Federal Motor Carrier Safety Regulations, Part 382.405 (f)(h)
and Part 382.413 (a)(b)(c)(e)(f), Bulk Transportation is required to request from previous Carriers any
information regarding POSITIVE controlled substance test results, alcohol test results with a
concentration of 0.04 or greater, or refusal to submit to such tests within the preceding three (3) years
of my application, which must include any positive pre-employment test results. Therefore, I
specifically authorize the release of such information by any and all employers and/or Carriers.
Additional Information:
I agree to furnish such additional information, and complete such examinations, as may be required
to complete my Independent Contractors file.
I specifically state that the Companies (listed above), its officers, and employees shall be held
harmless from any and all liability incurred through the investigation of my character and background.
I hereby specifically release from liability any previous Contractor including the above listed
Companies, or any other information source who may provide information regarding my work record,
reputation, reason for termination of Contract, accident record, or any other information that any of
them may have concerning me, whether such information is of record or not.
I further declare that a copy of this Information Release Authorization, whether signed originally by
me or photocopied, shall have the same effect as an original document.
SIGNATURE DATE
PRINTED NAME SOCIAL SECURITY NUMBER
File Name: Lease Operator Release Authorization – Rev2 Revision Date: 09/06/06
Bulk Transportation WestCoast Bulk Transportation DTI
Applicant Notice and Agreement
NAME: POSITION:
NOTICE!
This Applicant Notice and Agreement must be carefully read and signed prior to filling out
an Independent Contractor application.
1. An individual may only apply for the job position shown above at this time. If your application indicates that you are
applying for another job or “any” job, your application will not be considered.
2. Any individual who desires accommodation or assistance in making application as an Independent Contractor at any
time during the application process should inform the facility manager or other designated hiring authority. (see
reverse side).
3. I understand that I will only be considered for the specific job position that I am applying for and that my application
will only be considered active for thirty (30) days from the date of application.
4. The purpose of the application form is to provide you with the opportunity to present your skills, experience, abilities,
and other personal attributes that meet the qualification requirements for the job position being applied for. It is in
your best interest to take your time and fully list the qualifications that you believe you have.
5. All of the applicable inquiries on the application must be completed and the information that you provide must be
accurate and truthful! If an inquiry is left blank, your application will not be considered. If you feel that the question
asked or information sought is not applicable, put N/A for a response.
6. Any false, inaccurate, or missing information will result in rejection of the application, or will result in termination of
Contract if such false or inaccurate information is discovered after the date of hire.
7. I understand that a consumer report which may contain public record information will be requested from DAC
Services, Tulsa, Oklahoma. This report may include the following types of information: names and dates of previous
Carriers, reason(s) for termination of Contract, work experience, accidents, etc. I further understand that such
report(s) may contain public record information concerning my driving record, worker’s compensation claims, credit,
bankruptcy proceedings, etc. from federal, state, and other agencies which maintain such records as well as
information from DAC concerning previous driving record requests made by others from such state agencies, state
provided driving records, and claims involving me in the files of insurance companies.
8. The Company uses an Independent Contractor entrance medical examination (“physical”) in accordance with
applicable laws. Any offer of Independent Contractor will be conditioned upon the applicant successfully passing this
exam. The Contractor’s entrance medical examination will be administered after the conditional offer Contract, but
before the performance of any job duties. If the applicant does not pass this exam, the conditional offer of a Contract
will be withdrawn and any Contract relationship shall cease. Additionally:
a) In accordance with applicable laws, Controlled Substance and Alcohol testing is required of all applicants.
Failure of such test(s), or the refusal to submit to such test(s), shall be considered a failure of the Independent
Contractor’s entrance medical examination.
b) All medical data and information from the Independent Contractor’s medical entrance examination shall be
treated as a confidential medical record as required by applicable law.
9. Certain job positions require the successful completion of skills test(s) such as the road test, typing test, mechanical
proficiency test, or other demonstration of skills appropriate to the job position. Any offer of a Contract will be
conditioned upon the successful completion of such test(s), if applicable. Any such skills test(s) required may be
administered after the conditional offer of a Contract, but before the performance of any job duties. If the applicant
does not pass the applicable skills test(s), the conditional offer of a Contract will be withdrawn and any Contract
relationship shall cease.
(over)
File Name: Lease Operator Applicant Notice & Agreement-Rev1 Date of Revision: 06/28/05 Page 1 of 2
Bulk Transportation WestCoast Bulk Transportation DTI
10. I fully understand that if my Contract places me in a position requiring the operation of motor vehicles of any size or
description owned, operated, or leased by the Company, that my continuing Contract may depend upon, among other
factors, insurability with the Company and that as an operator of such vehicles I may be subject to immediate
termination if I become uninsurable due to traffic violations or accident involvement, irrespective of fault or cause,
during the course of my Contract.
11. If entered into a Contract, I agree to conform to the rules, regulations, and policies of the Company and understand
that, in accordance with applicable laws and regulations, my Contract is “at will” and may be terminated with or
without cause at any time, with or without notice, at the option of either myself or the company.
APPLICANT’S SIGNATURE DATE
NOTICE
THE FOLLOWING IS TO BE COMPLETED ONLY IF YOU ARE DECLARING A DISABILITY
AND ARE REQUESTING REASONABLE ACCOMMODATION
INVITATION TO REQUEST REASONABLE ACCOMMODATION
FOR APPLICANTS WITH A DISABILITY
Any applicant with a disability who needs reasonable accommodation in any step of the hiring process to help him or her
demonstrate his or her qualifications to perform the duties of the job for which the individual is applying may so request
such reasonable accommodation at any time during the application and/or skills demonstration process.
I hereby declare a disability under the Americans with Disabilities Act and request reasonable accommodation in the
application and/or skills demonstration process.
APPLICANT’S SIGNATURE DATE
File Name: Lease Operator Applicant Notice & Agreement-Rev1 Date of Revision: 06/28/05 Page 2 of 2
Bulk Transportation WestCoast Bulk Transportation DTI
ACKNOWLEDGMENT OF DRUG/ALCOHOL TESTING PROCEDURES
The following must be read, understood, and signed, acknowledging such understanding, by every
Contractor of Bulk Transportation.
If English is not the Contractor’s primary language, Bulk Transportation will provide an interpreter,
who shall also sign this form.
Bulk Transportation operates under a “ZERO-TOLERANCE” Drug and Alcohol Abuse Policy and
Program.
• Each Contractor will be tested for drugs and alcohol at the following times:
1. Prior to hire
2. Random – A minimum of once every two years
3. Post-Accident or Incident
4. For reasonable cause
• Consequences of Positive* test results:
1. At pre-hire, applicant will not be hired
2. At random, Contract shall be terminated
3. After an accident or incident, Contract shall be terminated
4. After reasonable cause, Contract shall be terminated.
* As determined by a qualified Medical Review Officer pursuant to the Bulk Transportation Drug and Alcohol
Abuse Policy and Program and applicable Federal Regulations
It is understood that any refusal to immediately report for a required drug or alcohol test will be
considered a Positive test result.
I hereby acknowledge that I have read and understand the above.
SIGNATURE DATE
PRINTED NAME
SIGNATURE OF TRANSLATOR, IF USED
File Name: Lease Operator Acknowledgement of D&A-Rev1 Date of Revision:06/28/05 Page 1 of 1
Bulk Transportation WestCoast Bulk Transportation DTI
CALIFORNIA
NOTICE OF INVESTIGATIVE CONSUMER REPORT
In connection with your application as an Independent Contractor, we have ordered an
investigative consumer report (as defined by California Law). This report may contain
information on your character, general reputation, personal characteristics and mode of
living.
This report has been or will be ordered from Total Information Services, Inc., dba DAC
Services, 4500 S. 129th E. Ave., Suite 200, Tulsa, Oklahoma 74134. The consumer
department telephone number is (800) 381-0645.
The scope of the report may include the following: names and dates of previous
Contracts, reason for termination of Contract, work experience, accidents, drug/alcohol
use. Such report may also contain public record information concerning your driving
record, worker’s compensation claims, credit, bankruptcy proceedings, criminal records
from federal, state and other agencies that maintain such records.
You have the right under Section 1786.22 of the California Civil Code to contact DAC
during reasonable hours (8:00 am to 5:00 pm CTZ Monday through Friday) to obtain all
information in your file for your review. You may obtain such information as follows:
1. In person at DAC’s offices, which address is listed above. You can have
someone accompany you to DAC’s offices. DAC may require this third party to
present reasonable identification. You may be required at the time of such visit
to sign an authorization for DAC to disclose to or discuss your information with
this third party.
2. By certified mail, if you have previously provided proper identification in a written
request that your file be sent to you or to a third party identified by you.
3. By telephone, if you have previously provided identification in writing to DAC.
DAC has trained personnel to explain any information in your file to you and if the file
contains any information that is coded, such will be explained to you.
File Name: Lease Operator CA Notice of Investigation-Rev1 Date of Revision: 06/28/05 Page 1 of 1
Bulk Transportation WestCoast Bulk Transportation DTI
DISCLOSURE AND RELEASE
(California Locations Only)
In connection with my application for Contract Service with you, I understand that consumer reports
that may contain public record information may be requested from DAC Services, 4500 S. 129th E.
Ave., Tulsa, Oklahoma 74134. DAC’s consumer department telephone number is (800) 381-0645.
These reports may include the following types of information: names and dates of prior Carriers,
reason for termination of contract, work experience, accidents, drugs/alcohol use. I further
understand that such reports may contain public record information concerning my driving record,
worker’s compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal,
state and other agencies which maintain such records.
I AUTHORIZE, WITHOUT RESERVATION; ANY PARTY OR AGENCY CONTACTED BY
DAC TO FURNISH THE ABOVE-MENTIONED INFORMATION.
I have the right to make a request to DAC, upon proper identification, to request the nature and
substance 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 DAC has previously furnished within the
two-year period preceding my request. I hereby consent to your obtaining the above information from
DAC, and I agree that such information which DAC has or obtains, and my Contract history with you if
I am hired, will be supplied by DAC to other companies that subscribe to DAC.
I hereby authorize procurement of consumer report(s). If contracted, this authorization shall remain
on file and shall serve as ongoing authorization for you to procure consumer reports at any time
during my contract period.
Print Applicant’s Name Applicant’s Signature
Social Security Number Date of Birth Today’s Date
Notice to California Applicants
You have a right to obtain a copy of any consumer report or investigative consumer report obtained
by The Company by checking the box provided below. The report will be provided to you within three
(3) business days after we receive the requested reports related to the matter investigated.
I request to receive a free copy of this report by checking this box. □
Under section 1786.22 of the California Civil Code, you may view the file maintained on you by DAC during
normal business hours. You may also obtain a copy of this file upon submitting proper identification and
paying the costs of duplication services, by appearing at DAC in person or by mail. You may also receive a
summary of the file by telephone. The agency is required to have personnel available to explain your file to
you and the agency must explain to you any coded information appearing in your file. If you appear in person,
a person of your choice may accompany you, provided that this person furnishes proper identification.
File Name: Lease Operator CA Disclosure & Release-Rev1 Date of Revision: 06/28/05 Page 1 of 1
