Brakebush Transportation, Inc

APPLICATION FOR EMPLOYMENT

BRAKEBUSH TRANSPORTATION, INC.

N4993 6TH DRIVE, WESTFIELD, WI 53964

AN EQUAL OPPORTUNITY EMPLOYER

To be filled out by the applicant only.Equal Opportunity Statement

Print or type neatly. Answer all questions.This company is an equal opportunity employer and fully subscribes to the principals of Equal Employment

If any question does not apply to you, putOpportunity. It is the policy of this company to provide employment compensation and other benefits related to

“N/A”. Incomplete applications will notemployment based on qualifications, without regard to race, color, religion, national origin, age, sex, veteran

be considered.status, or disability, or any other basis prohibited by federal or state law. As an equal opportunity employer, this

company intends to comply fully with all federal and state laws and the information requested on this application

**********************************will not be used for any purpose prohibited by law. Disabled applicants may request any needed accommodation

Application accepted_____ Rejected_____

Date of Application______

PLEASE PRINT

Last Name: / First: / Middle Initial: / Social Security Number:
Street Address: / City:______
County:______/ State: / Zip Code: / Phone Number:
Previous Address If Less than 3 Years at Above:: / City:______
County:______/ State / Zip Code / How Long?
Date Available for Employment: / Phone number where you can be reached if different from above:
Email Address:
Yes / No

Date of Birth: _____ / _____ / _____ Can you provide proof of age?

Required for Truck Drivers Only.

Have you the legal right to work in the United States?

Are you currently working?

Are you on layoff or subject to recall?

Are you aware of all D.O.T. regulations and logging procedures?

Are you capable of performing the essential functions of the position for which you are applying

with or without accommodations?

Do you have at least two years of accident free (interstate) experience with a reefer?

If yes, how many years?

Are you willing to work required overtime? Are you willing to work any day of the week and any time of day?

Are you willing to drive any geographical area? If not, what areas do you exclude?

Occasionally, we havefreight requiring hand unloading and palletizing for the customer. Would this be objectionable or create a morale problem?

Have you ever been disciplined for violating safety rules?

If yes, how often and for what?

Have you ever been discharged by an employer?

If yes, please explain.

Have you been convicted of a felony within the last 7 years? (A conviction will not necessarily bar employment. We will evaluate thecircumstances of the offense(s) as to a substantial relationship to the circumstances of the job). We reserve the right to use information outside the 7 year time frame.

What was your number of non-medically related absences or tardiness in the last 12 months that you worked?______

EDUCATION

School / Name and Location / Highest Grade
Completed / Graduated
Yes No / Degree Awarded / Major Field
Of Study
High School
Tech School
College
Other

If you are currently attending school, Where?______What type?______

EMPLOYMENT HISTORY

All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three (total of ten year employment record).

Continued on Next Page

*Any gaps in employment and/or unemployment must be explained. Any gaps in work history not explained will render this application null and void.

**The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in Interstate commerce used to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver) for compensation; or (3) is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

If employed, may we contact your present employer?Yes_____No_____

Have you filed an application here before?Yes_____No_____

Have you ever been employed here before?Yes_____No_____

WORK OR EDUCATION REFERENCES WE MAY CONTACT (e.g. former or present employers, supervisors, school advisors or faculty. DO NOT list relatives)

Name / Position & Company / Location / Phone Number

ACCIDENT RECORD (for Past 3 Years)

If no accidents within the last 3 years – check here _____

Date
(month/year) / Nature of Accident
(head-on, rear-end, upset, etc.) / Number of Fatalities / Number of Injuries / Hazardous Materials
Spill?

TRAFFIC CONVICTIONS AND FORFEITURES (for Past 3 Years)

If no traffic convictions and/or forfeitures in the past 3 years – check here _____

Date Convicted
(month/year) / Location
(city/state) / Violation
(other than parking) / Penalty

LICENSE INFORMATION

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
License
Information / State / License Number / Type (CDL, Etc.) / Expiration Date

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

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

IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS.

DRIVING EXPERIENCE

Class of Equipment / Type of Equipment
(Van, Tank, Flat, Etc.) / Dates
From To / Approx. No. of Miles
(total driven)
Straight Truck
Tractor and Semi-Trailer
Tractor – Two Trailers
Other (explain type)

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?______

______

EXPERIENCE AND QUALIFICATIONS – OTHER

Show any trucking, transportation or other experience that may help in your work for this company:______

______

List courses and training (other than shown elsewhere on this application):______

______

List special equipment or technical materials you can work with (other than those already shown):______

______

PLEASE USE AN EXTRA SHEET OF PAPER TO ADD ADDITIONAL EMPLOYERS OR TO EXPLAIN ANY QUESTION THAT REQUIRES MORE INFORMATION.

MOTOR VEHICLE RECORD RELEASE AND AUTHORIZATION FORM

TO: Wisconsin Department of Transportation

The undersigned does herby authorize the release and delivery of all motor vehicle driving

records relating to the undersigned, including but not limited to personal information, to my

employer and its insurance agent, whose names and addresses are as follows:

Name and Address of Employer:

Brakebush Transportation, Inc.

N4993 6th Drive

Westfield, WI 53964

Name and Address of Insurance Agent;

Marsh McClellan Insurance Agency.

Lorne D. Tschanz, Account Executive

3701 E. Evergreen Dr.

Appleton, WI 54913

This authorization shall continue in effect until revoked by the undersigned in a subsequent

writing delivered to you.

Signature:______

Date:______

Full Name:______

Address:______

Driver’s License Number:______

Issuing State:______Expiration Date:______

Important Notice Regarding Background Reports from the PSP Online Service

In connection with your application for employment with Brakebush Transportation, Inc., 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 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 Brakebush Transportation, Inc., (“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 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 DataQ’s 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 appearon 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 (Please Print) Signature Date:

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

LAST UPDATED 12/22/2015

REQUEST FOR INFORMATION

FROM PREVIOUS EMPLOYER

______Leave Blank______

______

Gentlemen:

The below named individual has made application to this company for a position as ______

______and states that he/she was employed by you as ______

from______to______.

We appreciate your time in completing, in confidence, the information requested below.

Thank you for your courtesy.

Sincerely,

Charlene Daye

Human Resources

Brakebush Transportation, Inc.

______

Name of Applicant:______Social Security Number:______

Employed from ______to ______as ______at wage or salary of ______

Did he/she drive motor vehicle for you? ______Straight Truck? ______Tractor/Semi Trailer? ______

Bus? ______Other (Specify)______

Was he/she a safe and efficient driver? ______Yes ______No

Reason for leaving your employ: Discharged: _____ Resignation: _____ Lay Off: ______Military Duty: ______

Was his/her general conduct satisfactory? ______Yes ______No

6. Please advise history of past driving record if available for past three years:______

______

7. Within the past two (2) years was this person tested for controlled substances? Yes_____ No_____

Did this person test positive? Yes_____ No_____
Did this person have an alcohol test with a BAC of .04 or greater in the

past two years? Yes_____ No_____

Did this person have an alcohol test with a BAC of .02 to .039 in the

past two years? Yes_____ No_____

Did this person refuse an alcohol or controlled substance test in the

past two years?Yes_____ No_____

If yes to A, B, C or D, explain naming Substance Abuse Professional, Etc.:______

______

Accident Information below requested in accordance with FMCSR Part 391.23 (Accidents within last 36 months)

Date / Nature of Accident / DOT Recordable / Preventable / Non-Preventable / Injuries / Fatalities / Cost

CONFIDENTIAL REPORT OF PERSONAL REFERENCES

Please indicate your opinion by placing a check in the appropriate column.

CHARACTERISTICS / EXCELLENT / GOOD / FAIR / POOR
Disposition, Tact, Ability to Get Along With Others
Initiative, Resourcefulness
Safety Habits
Driving Skill
Attitude
Loyalty

Is there anything else I should take into consideration before I hire this candidate? If above is yes, please comment: ______

______

Signature:______

Name (Please Print)______

Title:______

Date:______

Brakebush Transportation, Inc.

Prospective Employee Name:______

(Please print)

The prospective employee is required by Sec. 40.25(j) to respond to the following questions:

Have you tested positive, on any pre-employment drug or alcohol testAdministered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

Check one:[ ] Yes[ ] No

Have you refused to test, on any pre-employment drug or alcohol testAdministered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

Check one:[ ] Yes[ ] No

If you answered yes, can you provide / obtain proof that you’ve successfully completed the DOT return-to-duty requirements?

Check one:[ ] Yes[ ] No[ } Not Applicable

I certify that the information provided on this document is true and correct.

Prospective Employee Signature:______Date:______

Witness Signature:______Date:______

BRAKEBUSH BROTHERS, INC.

AFFIRMATIVE ACTION QUESTIONNAIRE

Name:______Date:______

One of the requirements of our Affirmative Action Program is to report the number of males/females and minority/non-minority employees and applicants. In order to accurately report this number, we would like you to complete the following questionnaire. Please indicate any of the following that apply:

Male:______Female:______

White:______Black or African American:______

Asian:______American Indian or Alaska Native:______

Hispanic (White Race Only)______Hispanic (All Other Races:______

Pacific Islander:______

This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans, (2) recently separated veterans, (3) active duty wartime or campaign badge veterans and (4) Armed Forces service medal veterans. These classifications are defined as follows:

A “disabled veteran” is one of the following: a veteran of the U.S. military, ground, naval or air service, who is entitled to compensation (or who but for the receipt of military retired pay, would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.

A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval or air service.

An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.