Employment Application Form

Signature *

First Name Last Name

Full Name *

First Name Middle Name Last Name

Social Security No.

Current Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

How Long?

Previous Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

How Long?

Are You a U.S. Citizen?

Yes No

Do you have the legal right to work in the United States?

Yes No

Phone Number

- Area Code Phone Number

E-mail

Birth Date

Month Day Year

Position Applying For

Date You Can Start

- Month - Day Year

Salary Desired

Have You Worked Here Before?

Yes No

If Yes, Where?

Date

Rate of Pay

Position

Reson for Leaving

Are you Employed?

Yes No

Have you ever been convicted of a felony?

Yes No

High School

Name of High School Attended

Number of Years Attended

Graduated?

Yes

College

Name of College/University Attended

Number of Years Attended

Graduated?

Yes

Area of Study/Degree

Graduate School

Name of Graduate School Attended

Number of Years Attended

Graduated?

Yes

Area of Study/Degree

Trade School/Other

Name of Trade/Technical/Other School Attended

Number of Years Attended

Graduated?

Yes

Area of Study/Degree

Current Employer

Name of Current Employer or NONE if not Employed

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Position

Salary

Reason for Leaving?

Start Date

- Month - Day Year

Where you subject to the FMCSRs while Employed?

Yes No

May We Contact?

Yes No

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

Yes No

Previous Employer

Name of Previous Employer

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Position

Salary

Reason for Leaving?

Start Date

- Month - Day Year

End Date

- Month - Day Year

Where you subject to the FMCSRs while Employed?

Yes No

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

Yes No

Previous Employer

Name of Previous Employer

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Position

Salary

Reason for Leaving?

Start Date

- Month - Day Year

End Date

- Month - Day Year

Where you subject to the FMCSRs while Employed?

Yes No

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

Yes No

	DATES	NATURE OF ACCIDENT	FATALITIES	INJURIES	HAZARDOUS MATERIAL SPILL
LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS
NEXT PREVIOUS

	LOCATION	DATE	CHARGE	PENALTY
1
2
3
4

DRIVER LICENSES

	STATE	SLICENSE NO.	TYPE	EXPIRATION DATE
1
2
3
4

A. Have you ever been denied a license, permit 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, give details

CLASS OF EQUIPMENT

	YES/NO	TYPE OF EQUIPMENT	DATES FROM (M/Y)	DATES TO (M/Y)	APPROX. NO. OF MILES (TOTAL)
STRAIGHT AND SEMI-TRAILER
TRACTOR-TWO TRAILERS
MOTORCOACH-SCHOOL BUS
OTHER

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?

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)

Reference 1

Name of Reference

Relationship

Years Acquainted

Phone

Email

Reference 2

Name of Reference

Relationship

Years Acquainted

Phone

Email

Reference 3

Name of Reference

Relationship

Years Acquainted

Phone

Email

Cover Letter

Resume

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL
ACCOUNT HOLDERS
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with _____________________________(“Prospective Employer”), Prospective
Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history
from the Federal Motor Carrier Safety Administration (FMCSA).
When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA
in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide
you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting
Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety
report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this
report.
When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer
uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding
you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic
notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and
the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide
you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy
of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a
driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together
with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights
under the Fair Credit Reporting Act.
Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct
any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to
https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this
data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.
Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or
imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes
were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State
citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law
will also appear, and remain, on a PSP report.
The Prospective Employer cannot obtain background reports from FMCSA without your authorization.
AUTHORIZATION
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize _______________________ (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP)
system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I
understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years
and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the
Prospective Employer to make a determination regarding my suitability as an employee.
I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has
the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by
submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot
change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.
I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report,
or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes
were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my
PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and
remain, on my PSP report.
I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I
sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby
authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

Name *

First Name Last Name

DRIVER'S APPLICATION FOR EMPLOYMENT

ATLANTIC COAST CARRIERS

TO BE READ AND SIGNED BY APPLICANT

FOR COMPANY USE PROCESS RECORD

TERMINATION OF EMPLOYMENT

APPLICANT TO COMPLETE

Employment Desired:

Education:

Employment History

Previous Employment:

Skills/Qualifications-DRIVER

EXPERIENCE AND QUALIFICATION-OTHER

References:

Cover Letter & Resume (Optional):

Send Application: