Employee Driver Application Page 2

Employee Driver Application Page 2

Name: SIN:

Date of Birth: Email:

Cell Phone: Home Phone:

Emergency Contact: Number:

Addresses for past 5 years required:

Street / City / Province / Postal Code
Current
Previous
Previous

Experience & Qualifications – Driver

Driver
Licenses / Province / License Number / Type / Expiration Date

Driving Experience

Class of Equipment /

Type of Equipment

/

Dates

/

Approximate

Number of Miles
From / To
Straight Truck
Tractor & Semi-Trailer
Tractor & 2 Semi Trailers
Other

Previous Employers past 5 Years

Release of Information (Confidential when Complete)

** THIS SECTION MUST BE COMPLETED IN FULL BY APPLICANT **

I, (SIN ), hereby authorize and

(Name of Applicant – please print clearly)

request that the companies listed below as well as CannAmm Inc. release a copy of my drug and/or alcohol test results and program participation information for the past 5 years to Penta Transport Ltd.

Penta Transport Contact: Cheryl Zmaeff Phone: (250) 753-5393 Fax: (250) 753-7560

LAST EMPLOYER:

Company: Contact:

Phone: Fax:

City: Prov: Reason For Leaving:

Position Held: Date From: to

SECOND LAST EMPLOYER:

Company: Contact:

Phone: Fax:

City: Prov: Reason For Leaving:

Position Held: Date From: to

THIRD LAST EMPLOYER:

Company: Contact:

Phone: Fax:

City: Prov: Reason For Leaving:

Position Held: Date From: to

FOURTH LAST EMPLOYER:

Company: Contact:

Phone: Fax:

City: Prov: Reason For Leaving:

Position Held: Date From: to

TO BE READ AND SIGNED BY APPLICANT

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. I hereby authorize and request that the above listed companies release all employment related information to Penta Transport. I hereby acknowledge and agree that I shall hold all parties harmless in all ways for any consequences arising from the release, interpretation, or misuse of the information released as a result of this request.

Signature of Applicant: Date: ______

Accident Record for Past 3 Years or More

(Attach sheet if more space is needed)

Date / Nature of Accident / Fatalities / Injuries
Last Accident
Next Previous
Next Previous
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Traffic Convictions and forfeitures for the past 3 years

(Other than parking violations) (Attach sheet if more space is needed.)

Location

/ Date / Charge / Penalty

A.  Have you ever been denied a license, permit or privilege to operate a motor vehicle? ¨ Yes ¨ No

B.  Has any license, permit or privilege ever been suspended or revoked? ¨ Yes ¨ No

C.  Have you ever tested positive or refused a drug and alcohol test? ¨ Yes ¨ No

If the answer to either A, B or C is YES, please provide a statement below giving details.

I, ______, certify that the following is a true and complete list

(Name of Applicant – please print clearly)

of traffic violations (other than parking violations) for which I have been convicted or forfeited

bond or collateral during the past 12 months outside of British Columbia.

Date / Offense / Location / Type of Vehicle Operated

If no violations are listed above, I certify that I have not been convicted or forfeited bond or

collateral on account of any violation required to be listed during the past 12 months.

Driver’s Signature

Reviewed by: (Signature) Title