driver application form - genoxtransportation

Genox Transportation Inc. | 2900 E San Augustine St. | Deer Park, TX 77536 Tel: (281) 479-0338

Driver Application Form

Date: Hire Date:

General Information Driver’s License

Name: (First, Middle, Last)

Date of Birth: (mm/dd/yyyy)

DL Number:

Social Security #: Telephone: DL State: DL Expires: (mm/dd/yyyy)

Address: (Street, City, State, Zip Code)

Duration:

List addresses for past 3 years:

Address: Duration: (Street, City, State, Zip Code) (Years)

Address:

Address:

(Street, City, State, Zip Code)

(Street, City, State, Zip Code)

Duration: (Years)

Duration: (Years)

Qualifications Education and Skills

Have you worked for this company before? Yes No Check the highest grade completed:

If yes, what dates? From: (month / year)

To: (month / year)

High School 9 10 11 12

Are you currently employed? Yes No College 1 2 3 4

Do you have driving experience? (If yes, please enter it below.) Yes No Graduate School 1 2 3 4 5 6

Driver Past Record

Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No If yes, describe:

Have you ever been disqualified for violation(s) of the Federal Motor Carrier Safety Regulations? Yes No If yes, describe:

Has any license, permit or privilege ever been suspended or revoked? Yes No If yes, describe:

Please list all states and provinces in which you operated a commercial motor vehicle during the past five years:

Please list any other relevant experience:

Please list any safe driving awards you have received:

Is there any reason you may not be able to perform all of the duties of the position for which you are applying? Yes No If yes, describe:

Do you have the legal right to work in the United States? Yes No

Type of School Name and City/State Start Date

(month / year) End Date (month / year)

Did you Graduate?

High School

College

Specialized

Other

Type of Equipment Start Date (month / year)

End Date (month / year)

Miles Operated

DL Endorsements: Please select all that apply.

Double/Triple

HazMat

Passenger

Tanker

HazMat Tanker

School Bus

(Years) DL Class: Please select only one.

A B C D E Non-CDL


Driver Past Record (continued)

Length of time driving a tractor trailer coast to coast:

Length of time driving a tractor trailer in winter:

Lenght of time driving a tractor trailer in the mountains

Makes of tractors driven:

Have you ever attended a truck driving school?

Have you ever been trained in Hazardous Materials?

Have you ever been trained in refrigerated equipment operations?

Have you ever transported cryogenic liquids/gases?

Have you ever been trained in tanker equipment operation?

Years Months Approximate Miles



Yes No

Yes No

Yes No

Yes No

No

Yes No Name:

Name:

Name:

Name:

Name:

Date

Date

Date

Date

Date

Yes No

Yes

Have you ever been disqualified from driving under the Federal Motor Carrier Safety Regulations?

Reason:

Have you served in the U.S. Armed Forces?

Branch: Dates: From To

Rank at Discharge: Type of Discharge Date of Discharge

If other than Honorable, please explain:

Military Status

Manual Yes No Automatic Yes No



Accidents and Violations Have you been involved in an accident in the past 3 years? (If yes, please complete the information below.) Yes No

Employment Information List all periods of employment and unemployment in reverse order starting with the most recent. CFR § 391.21(b)(11) requires 3 years history to beverified. For drivers applying to operate a commercial motor vehicle requiring a CDL, the 7-year period preceding the 3 years of history must be recorded for a total of 10 years, or to the extent of which the applicant has worked. (If more space is needed, please use Employment Information addendum.)

If gap between employers, indicate reason: Unemployed Attending School Self-Employed Other:

Employer Name:


Telephone: Facsimile:

Position:

Supervisor’s Name: From: To: Leaving: Salary:

Employed Reason for Ending

(month/year) (month/year)

CDL Required? Were you subject to the FMCSR Was the job a safety-sensitive function in any DOT-regulated mode subject to Yes No while employed? Yes No alcohol & controlled substance testing required by 49 CFR Part 40? Yes No


Employer Name:



Position:





Date of Accident: (mm/dd/yyyy)

Location: (City, State)

Type of Vehicle Operated:

Describe the Accident:

No. of Injuries: No. of Fatalities: Was HazMat (other than from fuel tanks) released? Yes No

Date of Accident: (mm/dd/yyyy)



Describe the Accident:

No. of Injuries: No. of Fatalities: Was HazMat (other than from fuel tanks) released? Yes No

Date of Violation: (mm/dd/yyyy)


Describe the Violation: Fine: $


DOT Regulation Cited:

Date of Violation: (mm/dd/yyyy)


Describe the Violation: Fine: $


DOT Regulation Cited:

Have you been involved in any violations in the past 3 years? (If yes, please complete the information below.) Yes No


Employer Name:



Position:







Employment Information (continued)


Employer Name: Telephone: Facsimile: Address:

(Street, City, State, Zip Code) Position:


Employed Reason for Ending (month/year) (month/year)

CDL Required? Were you subject to the FMCSR Yes No while employed? Yes No

Was the job a safety-sensitive function in any DOT-regulated mode subject to alcohol & controlled substance testing required by 49 CFR Part 40? Yes No






























Affidavit of Gap in Employment

Driver Name:

Dates of Gap in Employment:

Reason for Gap in Employment:

Unemployed Attending School (School Name)

Self-Employed or Employed by Individual (Individual’s Name)

Other (Indicate Reason)

CDL Required: Yes No

Were you subject to the FMCSR’s: Yes No

Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing required by 49 CFR Part 40: Yes No

















Applicant’s Signature: Date:

To

To

To



Applicant Certification

By signing this statement, I certify that:

• This application for employment/contract was completed by me and that all entries on it and the information containedwithin it are true and correct to the best of my knowledge.

• As required by § 383.21 of the FMCSR’s, I only have one motor vehicle operator’s license.

Furthermore, I authorize you (the Company or agencies) 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/contract decision. I hereby release any and all of; the employers, the schools, the health care providers, the Company and their subsidiaries, as well as the other persons associated with this application for employment/contract and the subsequent processes and procedures from all liability in response to inquiries and the releasing of information in connection with my application. In the event of employment/contract, I understand that false or misleading information given in my application or interview(s) may be considered fraud and could be construed as criminal, and may be grounds for termination and permanent discharge from this company. I understand that I am required to abide by all rules and regulations of the Company as outlined in the company policies and statements.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) 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:

a.) Review information provided by previous employers; b.) Have errors in the information corrected by previous employers and for those previous employers to resend the corrected

information to the prospective employer; and c.) 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.

Applicant’s Signature: Date:

The Company is an equal opportunity employer and does not discriminate on the basis of race, color, religion, gender, age, sexual orientation, national origin or ancestry, physical or mental disability, marital status, pregnancy, veteran status, medical condition, or any other protected status as defined by the law.

For Completion by Company Representative

Reviewed by: Date:

Comments:

GENOX WEST TRANSPORTATION, LLC APPLICANT NOTIFICATION AND RELEASE FORM

APPLICANT NOTIFICATION (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 the purpose of a background investigation to see if you qualify for our program. These reports are required by Sections 382.413, 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations.

AUTHORIZATION AND GENERAL RELEASE

I hereby authorize GENOX WEST TRANSPORTATION, LLC, and all of their agents, including Warriner Solutions, LLC Houston, TX. to request and receive any information and records concerning me, including, but not limited to, consumer credit, criminal record history, worker’s compensation claims, driving record,

past employment history, military service, bankruptcy proceedings, civil and educational data and reports, from any individuals, corporations, partnerships, associations, institutions, schools, governmental agencies and other departments, courts law enforcement and licensing agencies, consumer reporting agencies and other federal, state agencies and entities, which maintain such records, including my present and previous employers. Information from Warriner Solutions, LLC concerning previous driving record requests made by others from such state agencies, and state provided driving records would also be requested.

I further release and discharge GENOX WEST TRANSPORTATION, LLC all of their agents, all of their subsidiaries and affiliates, and every employee and agent of any of them, and all individuals and personal business, private or public entities of any kind, including Warriner Solutions, LLC of Houston, TX. from any and all claims and liability arising out of any request(s) for, or receipt of information or records pursuant to this authorization, or arising out of any compliance, with such request(s). I authorize the procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable. I understand that I have the right to make a written request within a reasonable period of time to Warriner Solutions, LLC Houston, TX.. 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 WARRINER SOLUTIONS, LLC has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from WARRINER SOLUTIONS, LLC, and I agree that such information which WARRINER SOLUTIONS, LLC has or obtains, and my contract history with you if I am contracted for services, will be supplied by WARRINER SOLUTIONS, LLC to other companies which subscribe to Warriner Solutions, LLC. APPLICANT’S STATEMENT OF RELEASE I HEREBY AUTHORIZE, WITHOUT RESERVATION, GENOX WEST TRANSPORTATION, LLC., OR ANY PARTY OR AGENCY CONTACTED BY GENOX WEST TRANSPORTATION, LLC., OR ITS PARTICIPATING COMPANIES, INCLUDING WARRINER SOLUTIONS, LLC IN HOUSTON, TX.TO DO A COMPLETE BACKGROUND INVESTIGATION IN ACCORDANCE WITH STATE AND FEDERAL LAWS. I AUTHORIZE THE RELEASE OF ANY INFORMATION REGARDING MY EMPLOYMENT, INCLUDING, BUT NOT LIMITED TO, ALL INFORMATION RELATED TO MY ALCOHOL AND CONTROLLED SUBSTANCE TESTING AND TRAINING RECRODS BY ANY FORMER EMPLOYERS, AND HOLD THEM HARMLESS OF ANY AND ALL LIABILITY FROM RELEASE OF SAID INFORMATION. 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 OR UNTIL WITHDRAWN BY ME IN WRITING.

Date Signed: Applicant’s Signature:

Print Name: Social Security Number:

driver application form - genoxtransportation

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