Employment Application - Gentry Trucking

APPLICATION FOR EMPLOYMENT

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Name

First Last

Phone

Other Phone

SSN

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Marital Status

Position Applying For

Position Duration

Have You Worked For This Company Before?

Previous Location

Position

Employed From

Rate of Pay

Reason For Leaving

Have You Worked For This Company Before?

Name Of Relative

Are You Currently Employed?

How Long Since Last Employment

Where Did You Hear About Us?

Expected Pay

EMPLOYMENT RECORD

§391.21 (B) (10) (i): a list of the names and addresses of the applicant’s employers during the 3 years preceding the date the application is submitted, (ii) the dates he or she was employed by the employer, (iii) the reason for leaving the employ of the employer, (iv) whether the applicant was subject to the FMCSRs while employed by that previous employer, (B) job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40; (11) for those drivers applying to operate a commercial motor vehicle as defined by part 383 of this subchapter, a list of the names and addresses of the applicant’s employers during the 7-year period preceding the 3 years contained in paragraph (b)(10)(totaling 10 years) of this section for which the applicant was an operator of a commercial motor vehicle, together with the dates of employment and the reasons for leaving such employment.

Total Years of Class A CDL Driving Experience(Required)

Last Employer

Employer's Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position Held

Is This Your Current Employer?

Employed From

Rate Of Pay

Reason For Leaving

FOR THOSE APPLYING AS DRIVERS:

Were you subject to the FMCSR's rule while Employed by this employer §391.21(10)(iv)?

Was this job a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

Did this employer do drug screening?

If yes, did you pass/fail?

EMPLOYMENT RECORD

§391.21(B)(5): The Issuing State, number, and expiration date of each unexpired commercial motor vehicle operator’s license or permit that has been issued to the applicant.

Drivers Licenses Held In The Past 3 Years Must Be Entered

Current License

License No

Type

Exp Date

Previous License 1

License No

Type

Exp Date

Previous License 2

License No

Type

Exp Date

§391.21(b)(8) A list of all violations of motor vehicle laws or ordinances (other than violations involving only parking) of which the applicant was convicted or forfeited bond or collateral during the 3 years preceding the date of the application is submitted. §391.21(b)(9) A statement setting forth in detail the facts and circumstances of any denial, revocation, or suspension of any license, permit, or privilege to operate a motor vehicle that has been issued to the applicant, or a statement that no such denial, revocation, or suspension has occurred.

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

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

Have you ever been disqualified for violations of the Federal Motor Carrier Safety Reg?

If you answered "YES" to either A, B, or C, explain in detail:

Provide Your Accident Record For The Past 3 Years Or More

Location

Date

Charge

Penalty

Please Provide All Traffic Convictions And Forfeitures For The Past 3 Years (Other Than Parking Violations)

§391.21(b)(7) A list of all motor vehicle accidents in which the applicant was involved during the 3 years preceding the date the application is submitted, specifying the date and nature if each accident and any fatalities or personal injuries it caused.

Last Accident

Nature Of Accident

Fatalities

Injuries

Hazardous Material Spilled

Driving Experience

§391.21(b)(6) The nature and extent of the applicant’s experience in the operation of motor vehicles, including the type of equipment (such as buses, trucks, truck tractors, semitrailers, full trailers, and pole trailers) which he/she has operated.

Class Of Equipment

Passanger Count

Type Of Equipment (Van, Tank, Flat, Etc)

Equipment Use Dates

Approx Total Miles Driven

Please List States Operated In For The Last Five Years

List Any Special Courses Or Training That Have Helped You As A Driver

Do You Hold Any Safe Driving Awards? If So From Whom?

OTHER EXPERIENCES AND QUALIFICATIONS

Courses Or Training In Platform Work

List Platform Equipment You Can Operate (Lift Truck, Etc.)

List Types Of Platform Experience And Years Of Each:

Number