EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION
Please note that in order to complete this application, you must upload copies or pictures of the following DOT and OSHA required documents
- Driver's License
- DOT Medical Card
- Social Security Card, Birth Certificate or US Passport
- OSHA 10 or higher
- OSHA Confined Space Certification
All applicants will be subject to a pre-employment drug test to be conducted at

Occupational Health 52 Crest Ave #7a, Winthrop, MA 617-846-0845

*DOT cards can be obtained from this location as well

Need OSHA Certifications?
- To take the OSHA courses and recieve your required certifications if you have not done so already click here
- If you have completed OSHA requirements and lost your physical certification proof, request a free copy at any time here

I. CONTACT INFORMATION
Name*

First NameMiddle NameLast Name
Email*
example@example.com
Social Security #*
xxx-xx-xxxx
Mobile Number*

Area CodePhone Number
Alt. Number

Area CodePhone Number
Current Mailing Address*

Street Address

Unit/Apartment #

CityState

Zip Code
Previous Address 1
Dates Resided
Previous Address 2
Dates Resided
Previous Address 3
Dates Resided
Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*
Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*

II. DRIVING EXPERIENCE
Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license." I certify that I do not have more than one motor vehicle license, the information for which is listed below.

DRIVER'S LICENSE INFO*

	STATE	LICENSE NO.	TYPE	EXPIRATION DATE
1

PLEASE FILL OUT THE TABLES TO THE BEST OF YOUR ABILITY, FOR FIELDS THAT DO NOT APPLY TO YOUR EXPIRIENCE PLEASE PUT "NA"

DRIVING EXPERIENCE*

	EQUIPMENT CLASS	EQUIPMENT TYPE	APPROX. NO. OF MILES	START DATE	END DATE
STRAIGHT TRUCK
TRACTOR AND SEMI-TRAILER
TRACTOR-TWO TRAILERS
OTHERS

ACCIDENT RECORD PAST 3 YEARS*

	DATES	TYPE (head-on, rear end, etc.)	NO. OF FATALITIES	NO. OF INJURIES	CHEMICAL SPILLS?
1
2
3

TRAFFIC CONVICTIONS AND FORFEITURES IN PAST 3 YEARS*

	DATE CONVICTED	VIOLATION	STATE/LOCATION	PENALTY
1
2
3

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?*

NOYES
IF YES, EXPLAIN
B. Has any license, permit or privilege ever been suspended or revoked?*

NOYES
IF YES, EXPLAIN

III. EMPLOYMENT HISTORY
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record)
MUST LIST THE COMPLETE MAILING ADDRESS: STREET NUMBER AND NAME, CITY, STATE AND ZIP CODE
Last Company Employed By*

IV. DRIVER RECORD SCREENING DISCLOSURE
I hereby authorize Embark Safety LLC and its designated agents and representatives to conduct a comprehensive review of my driver record background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include information about my names, motor vehicle records, license verification. Upon Request, Embark Safety LLC will supply a copy of the completed consumer report along with a copy of an individual’s rights under the Fair Credit Reporting Act.

Authorization and Release

I authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation, or public agency may have. I authorize the full release of the information described above, without any reservation, throughout any duration of my employment at Rapid Flow Inc. I certify that all information provided below is correct to the best of my knowledge. This authorization and consent shall be valid in original, fax, or copy form. The following information is required by law enforcement agencies and other entities for identification purposes when checking records. It is confidential and will not be used for any other purpose.
Applicant's Full Name*

First NameMiddle NameLast NameSuffix
Driver's License Number*
State*
Date of Birth*

MonthDayYear
Date
Notice to California Applicants: Under section 1786.22 of California Civil Code, you have the right to request from Embark Safety LLC, upon proper identification, the nature and substance of all information in files pertaining to you, including the sources of information, and recipients of any reports on you, which Embark Safety LLC has previously furnished within the two-year period preceding your request. You may view the file maintained on you by Embark Safety LLC during normal business hours. You may also obtain a copy of this file upon submitting proper identification. Upon making a written request, you may receive a summary of your report. Notice to Maine Applicants: Under Chapter 210 Section 1314 of Maine revised Statutes, you have the right, upon request, to be informed within 5 business days of such a request to whether or not an investigative consumer report was requested. If such report was obtained, you may contact the Consumer Reporting Agency and request a copy. Notice to Massachusetts Applicants: Under Mass. Ann. Laws chapter. 93 §§ 50, a Consumer Reporting Agency may furnish a report if intended to be utilized for employment purpose
Signature*

Clear
Date of Birth*

MonthDayYear
Date
Are You Applying for a CDL Position?*

yesno

VIII. PERSONAL REFERENCES

List three persons for references, other than family members, who have knowledge of your safety habits
Reference 1*
Reference 2*
Reference 3*
It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my application file. It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be
disqualified without recourse. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Date*

MonthDayYear
Date
Applicant Signature*

Clear

VIIII. BACKGROUND INFORMATION REQUEST AND WAIVER
Personal Data
Name*

First NameMiddle NameLast Name
Residential Address*

Street Address

Street Address Line 2

CityState

Zip Code
D.O.B.*

MonthDayYear
Date
Social Security Number*
xxx-xx-xxxx
Driver's License #*
DL State*

Street Address

Street Address Line 2

CityState

Zip Code
Print name in blank space
Applicant signature*

Clear
Date*

MonthDayYear
Date

X. COMPANY POLICIES

Read the policies then sign and date
Rapid Flow Inc. Non-Harassment Policy
Receipt of the No-Harassment Policy

I have this day received a copy of the company’s No-Harassment policy. I understand that I am responsible for reading the policy and procedures contained therein. I understand that the policy’s replaces any and all prior policies and practices of the company.

I agree to abide by the policy and procedures. I understand that the policy and procedures may be added to, deleted or changed by the company at any time.

If I have any questions regarding the content or interpretation of the policy or procedures, I will bring them to the attention of my supervisor or any member of management.

Please sign below to acknowledge receipt and understanding of this notice.
Print Name*

First NameMiddle NameLast Name
Applicant Signature*

Clear
Date*

MonthDayYear
Date
VEHICLE INSPECTION POLICY
Vehicle Inspection Policy

To All Employees:

It is a mandatory requirement for every driver to fill out a vehicle inspection report prior to leaving the shop. A walk around checking fluids is a requirement as well not only for DOT but Company Policy. All vehicle inspection reports are to be put in the basket above FedEx Cabinet completely filled out and notes taken of specific repairs that need to be done. Failure to follow these procedures will result in a 1 day suspension and multiple occurrences may result in a longer suspension or termination.

Please sign below to acknowledge receipt and understanding of this notice.
Print Name*

First NameMiddle NameLast Name
Applicant Signature*

Clear
Date*

MonthDayYear
Date
MSO SECURITY GUIDELINES
Print Name*

First NameMiddle NameLast Name
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Please Print the following legal tax forms, fill them out and IF you are unable to upload the completed forms to this application, please email, fax or bring to the Rapid Flow Inc. HR office:

80 Hitchborn st Revere, MA 02151

fax: 781-289-5661

email: ameads@rapidflowinc.com
W4
Please Upload completed W4
M4
Please Upload completed M4
I-9
Please Upload completed page 1 of I-9
Upload List A Document
Upload List B and C Documents
Direct Deposit
Upload completed Direct Deposit File
Blue Cross Blue Shield of Massachusetts Waiver
Upload completed BCBS Waiver File
Do you anticipate accepting BCBS health care coverage via RapidFlow Inc?

yesno
Required Certifications and Documentation
Upload OSHA 10 (or Higher) File*
Upload OSHA Confined Spaces File*
Upload DOT Medical Card*
Upload Driver's License*
Social Security Card*
Are you applying for a Catch Basin position?

yesno
Hoisting License
Additional Certifications
Legal Citizenship Documents (ex: green card)
Should be Empty:

	Dates to	Dates From	Approximate # of Miles Total
Straight Truck
Tractor and Semi-Trailer
Tractor-two trailers (doubles)
Tractor-three trailers (triples)
Tractor-Tanker trailer
other* specify below

	Date of Accident	Nature of Accident (head on, rear end, etc)	# of Fatalities	# of injuries
1
2
3
4

	Date	Location	Charge	Penalty
1
2
3
4

	State	type	endorsements	expiration date
1
2
3
4

EMPLOYMENT APPLICATION

I. CONTACT INFORMATION

II. DRIVING EXPERIENCE

III. EMPLOYMENT HISTORY

IV. DRIVER RECORD SCREENING DISCLOSURE

V. DRIVER APPLICATION/QUALIFICATION

VI. DRIVER HISTORY

VII. EMPLOYMENT HISTORY

VIII. PERSONAL REFERENCES

VIIII. BACKGROUND INFORMATION REQUEST AND WAIVER

X. COMPANY POLICIES

VEHICLE INSPECTION POLICY

MSO SECURITY GUIDELINES

Required Certifications and Documentation