AFC Logistics, Inc.

Application for Employment

AFC Logistics, Inc.

11349 US Hwy 52 S

Clarks Hill, IN 47930
Location applying at*
Personal Information
Name*

First NameMiddle NameLast Name
Social Security Number*
Date of Birth*

MonthDayYear
Phone Number*
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Relation*
Emergency Contact's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact's Phone Number*
License Number*
Expiration*

MonthDayYear
State of Issue*

Street Address

Street Address Line 2

City

Zip Code
License Type*
Have you ever been denied a license, permit or privilege to operate a motor vehicle?*

YesNo
Has any license, permit or privilege ever been suspended or revoked?*

YesNo
Explanation*

DECLARATION OF EMPLOYMENT STATUS
I understand that I must provide my complete employment history for the past 3 years, and all CDL required employment for the 7 years preceding that. Any gaps in employment longer than 1 month are explained as follows:
To

MonthDayYear
From

MonthDayYear
During this time, I was engaged in the following activity:
In addition:

I was not employed by any company or individualI was not convicted of any criminal act involving the use of a commercial motor vehicle or while driving a commercial motor vehicle
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally inquiries regarding medical history will be made only if and after a conditional offer of employment 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 employment, I understand that false or misleading information given in my application or interviews may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employers will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23 (d) and (e). I understand that I have the right to:
- Review information provided by the previous employers;
- Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
- Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
Signature*

Clear
Name

First NameMiddle NameLast Name
Date

MonthDayYear

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
In accordance with the provisions of Section 604 (b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports and required by Sections 382.413 and 391.25 of the Federal Motor Carrier Safety Regulations.
Signature*

Clear
Name

First NameMiddle NameLast Name
Date

MonthDayYear

ALCOHOL AND CONTROLLED SUBSTANCE

CONSENT AND RELEASE
Have you ever refused to be tested for drugs & alcohol at any time in the last 2 years?*

YesNo
Have you ever tested positive for drugs or alcohol at any time in the last 2 years?*

YesNo
Have you ever tested positive on any pre-employment drug or alcohol test for a job which you applied for but did not obtain?*

YesNo
If you answered yes to any of the above questions, provied a statement of explanation and provide proof of return to duty process.*
I understand that, as required by the Federal Motor Carrier Safety Regulations and company policy, all drivers must submit to alcohol and controlled substance testing as a condition of employment. I also understand that any offer of employment will be contingent upon the results of an alcohol and controlled substance test.
Therefore, I agree to submit to the following alcohol and controlled substance tests in accordance and as defined by the Federal Motor Carrier Safety Regulation and this company’s policies:
- Pre-Employment, to determine employment eligibility
- Random
- Reasonable Suspicion
- Post Accident
I certify that I have read, understand, and agree to abide by the condition of this consent and release form.
Signature*

Clear
Name*

First NameMiddle NameLast Name
Date*

MonthDayYear

CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:
1. You, as a commercial vehicle driver, may not possess more than one license. The only exception is if a state requires you to have more than one license. This exception is allowed until January 1, 1990.
  If you currently have more than one license, you should keep the license from your state of residence, and return the additional licenses to the states that issued them. Destroying a license does not close the record in the state that issued it: you must notify the state. If a multiple license has been lost, stolen, or destroyed, you should close your record by notifying the state of issuance that you no longer want to be licensed by that state.
2. Sections 392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it to your employing motor carrier and the state that issued your license within 30 days.
DRIVER CERTIFICATION: I certify that I have read and understand the above requirements.

The following license is the only one I will possess:
License Number*
State of Issue*

Street Address

Street Address Line 2

City

Zip Code
Expiration*

MonthDayYear
Signature*

Clear
Name*

First NameMiddle NameLast Name
Date*

MonthDayYear

Motor Vehicle Record

Disclosure & Release Form
In connection with my ongoing employment or my application for employment, should I have or secure a position with AFC Logistics, Inc., I understand that a motor vehicle record, which contains public record information, may be requested. I further understand that such report(s) will contain personal information and public record information concerning my driving record from federal, state, and other agencies that maintain such records, as well as independent services that provide driving record information.

I authorize, without reservation, any party or agency contacted to furnish the above mentioned information to AFC Logistics, Inc. or its agent.

I hereby authorize procurement of my motor vehicle report. If hired, this authorization shall remain on file and shall serve as ongoing authorization for AFC Logistics, Inc. to procure such reports at any-time during my employment. I also authorize AFC Logistics, Inc. commercial auto insurer and agent to use this information in conjunction with loss control and safety review efforts.
Name*

First NameMiddle NameLast NameSuffix
Driver License Number*
State Of Issuance*

Street Address

Street Address Line 2

CityState

Zip Code
Signature

Clear
Date*

MonthDayYear
Should be Empty:

Personal Information

Driver Experience

Accidents

Tickets

Employment Record

DECLARATION OF EMPLOYMENT STATUS

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

ALCOHOL AND CONTROLLED SUBSTANCE

CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

Motor Vehicle Record