GREAT LOGISTICS EXPRESS, LLC. Application for Employment
DRIVER’S APPLICATION
FOR EMPLOYMENT
Applicant Date of
Name Application
Company GREAT LOGISTICS EXPRESS, LLC______
Address 7709 WALLACE STREET
City MERRILLVILLE, IN 46410
Tel. /Fax 219 2218832 / 866 568 4461
In compliance with Federal and State equal employment opportunity law, qualified applicants
are considered for all positions without regard to race, color, sex, national origin, age, marital
status, veteran status, non-job related disability, or any other protected group status.
I authorize you 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 decision. (Generally, inquiries regarding medical history will be made only if and alter a conditional offer of employment has been extended.)
I hereby release employers, schools, health care providers and other persons from all liability in responding to inquires and releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
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:
• Review information provided by previous employers;
• Have errors in the information corrected by previous employers and for those previous employers to re-send
corrected information to the prospective employer; and
• Have a rebuttal statement attached to the alleged erroneous information, if the pervious employer(s) and I
cannot agree in the accuracy if the information.
Signature ______Date ______
FOR COMPANY USE
PROCESS RECORDAPPLICANT HIRED ______REJECTED ______
DATE EMPLOYED ______POINT EMPLOYED ______
DEPARTMENT ______CLASSIFICATION ______
(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)
SIGNATURE OF INTERVIEWING OFFICER ______
TERMINATION OF EMPLOYMENT
DATE
TERMINATED ______DEPARTMENT RELEASED FROM ______
DISMISSED ______VOLUNTARILY QUIT ______OTHER ______
TERMINATION REPORT PLACED IN FILE ______SUPERVISOR ______
APPLICANT TO COMPLETE
(Answer all questions – please print)
Position(s) Applied for
Name Social Security No.
LastFirstMiddle
List your addresses of residency for the past 3 years.
Current
Address
StreetCity Phone How Long?
State, Zip CodeYears/Months
Previous How Long?
Addresses Street City State and Zip CodeYears/Months
How Long?
Street City State and Zip CodeYears/Months
How Long?
Street City State and Zip CodeYears/Months
Do you have the legal right to work in the United States?
Date of Birth Can you provide proof of age?
(Required for Commercial Drivers)
Have you worked in this company before? Where?
Dates: From To Rate of Pay Position
Reason for leaving
Are you now employed? If not, how long since your last employment
Who referred you? Rate of pay expected
Have you been bonded? Name of bonding company
(Answer only if a job requirement)
Have you ever been convicted of felony?
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment – all circumstances are considered.
Is there any reason you might be unable to perform the functions of the job witch you have applied as described in the attached job description?
If yes pleaseexplain you wish
EMPLOYMENT HISTORY
In compliance with CFR 49 parts 391.21 (b (11) a completerecord of employment for the past ten years is necessary for your application to be processed. Please list your present employer first. All periods of time must be accounted for during this ten-year period, including military service, self-employment, non-driving positions and periods of unemployment. Provide complete address and phone numbers, including area codes and zip codes.
From:To: Company Name:
Phone:( ) - Street Address:
Position: City: State: Zip:
Type of Equipment Operated: Ending Pay:
Were you subject to FMCSR’s? Yes No
Was your job designated as a Safety Sensitive Function? Yes No
Reason For Leaving:
From:To: Company Name:
Phone:( ) - Street Address:
Position: City: State: Zip:
Type of Equipment Operated: Ending Pay:
Were you subject to FMCSR’s? Yes No
Was your job designated as a Safety Sensitive Function? Yes No
Reason For Leaving:
From:To: Company Name:
Phone:( ) - Street Address:
Position: City: State: Zip:
Type of Equipment Operated: Ending Pay:
Were you subject to FMCSR’s? Yes No
Was your job designated as a Safety Sensitive Function? Yes No
Reason For Leaving:
From:To: Company Name:
Phone:( ) - Street Address:
Position: City: State: Zip:
Type of Equipment Operated: Ending Pay:
Were you subject to FMCSR’s? Yes No
Was your job designated as a Safety Sensitive Function? Yes No
Reason For Leaving:
From:To: Company Name:
Phone:( ) - Street Address:
Position: City: State: Zip:
Type of Equipment Operated: Ending Pay:
Were you subject to FMCSR’s? Yes No
Was your job designated as a Safety Sensitive Function? Yes No
Reason For Leaving:
From:To: Company Name:
Phone:( ) - Street Address:
Position: City: State: Zip:
Type of Equipment Operated: Ending Pay:
Were you subject to FMCSR’s? Yes No
Was your job designated as a Safety Sensitive Function? Yes No
Reason For Leaving:
From:To: Company Name:
Phone:( ) - Street Address:
Position: City: State: Zip:
Type of Equipment Operated: Ending Pay:
Were you subject to FMCSR’s? Yes No
Was your job designated as a Safety Sensitive Function? Yes No
Reason For Leaving:
From:To: Company Name:
Phone:( ) - Street Address:
Position: City: State: Zip:
Type of Equipment Operated: Ending Pay:
Were you subject to FMCSR’s? Yes No
Was your job designated as a Safety Sensitive Function? Yes No
Reason For Leaving:
From:To: Company Name:
Phone:( ) - Street Address:
Position: City: State: Zip:
Type of Equipment Operated: Ending Pay:
Were you subject to FMCSR’s? Yes No
Was your job designated as a Safety Sensitive Function? Yes No
Reason For Leaving:
From:To: Company Name:
Phone:( ) - Street Address:
Position: City: State: Zip:
Type of Equipment Operated: Ending Pay:
Were you subject to FMCSR’s? Yes No
Was your job designated as a Safety Sensitive Function? Yes No
Reason For Leaving:
From:To: Company Name:
Phone:( ) - Street Address:
Position: City: State: Zip:
Type of Equipment Operated: Ending Pay:
Were you subject to FMCSR’s? Yes No
Was your job designated as a Safety Sensitive Function? Yes No
Reason For Leaving:
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
DATES / NATURE OD ACCIDENT(HEAD-ON, REAR-END, UPSET, ETC.) / FATALITIES / INJURIES / HAZARDOUS MATERIAL SPILL
LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS
TRAFFIC CONVICTIONS AND FOREFEITURES FOR THE 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
LOCATION / DATE / CHARGE / PENALTY(ATTACH SHEET IF MORE SPACE IS NEEDED)
EXPERIENCE AND QUALIFICATIONS – DRIVER
List all driver licenses or permits held in the past 3 years
DRIVER LICENSES / STATE / LICENSE NO / TYPE / EXPIRATION DATE- Have you ever 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, GIVE DETAILS
DRIVING EXPERIENCE CHECK YES OR NO
FROM (M/Y) TO (M/Y) / APPROX.NO OF MILES (TOTAL)
STRAIGHT TRUCK
/
(VAN,TANK,FLAT,DUMP,REEFER)
TRACTOR AND SEMI-TRAILER
/
(VAN,TANK,FLAT,DUMP,REEFER)
TRACOR-TWO TRAILERS
/
(VAN,TANK,FLAT,DUMP,REEFER)
TRACTOR-THREE TRAILERS
/
(VAN,TANK,FLAT,DUMP,REEFER)
MOTOR COACH-SCHOOL BUS MORE THAN 8
PASSENGERS
/
__
MOTOR COACH-SCHOOL BUS MORE THAN1
PASSENGERS
/
__
OTHER
LIST STATES OPERATED IN FOR 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 THE COMPANY ______
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)
EDUCATION
HIGHEST GRADE COMPLETED: HIGH SCHOOL: COLLEGE:
LAST SCHOOL ATTENDED: (NAME)(CITY,STATE)
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.
Signature: Date:
Motor Vehicle Driver’s
CERTIFICATION OF COMPLIANCE
WITH DRIVER LICENSE REQUIREMENTS
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 16 people, or transports hazardous materials that require placarding.
The requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:
1)POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator’s license.
If you have more than one license, keep the license from your state of residence and return the additional license to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you may notify the state. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state.
2)NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION:
Sections 391.15(b)(2) 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to 10 your employing motor carrier, and 20 the state that issued your license (if the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing.
The following license is the only one I will possess:
Drivers License No. State Exp. Date
DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.
Driver’s Name (Printed):
Driver’s Signature: Date
Notes:
MOTOR VEHICLE DRIVERS
Certification of Violations/Annual Review of driving record
MOTOR CARRIER INSTRUCTION: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list if all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or an account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information on this form.
DRIVER REQUIREMENTS: Each driver shall furnish the as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 39127).
COMPLETED BY DRIVER – CERTIFICATION OF VIOLATIONS
NAME OF DRIVER(PRINT) / SOCIAL SECURITY NUMBER / DATE OF EMPLOYMENTHOME TERMINAL
(CITY AND STATE) / DRIVER’S LICENSE NUMBER STATE / EXPIRATION DATE
I certify that the following is true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.
(If you have had no violations, check the following box □- NONE)
DATE OFFENCE 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 (other than those I have provided under Part 383) required to be listed the past 12 months.
Date of certification ______Driver’s signature ______
COMPLETED BY MOTOR CARRIER – ANNUAL REVIEW OF DRIVING RECORD
MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section 391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below.I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find that he/she (cheek one):
□ Meets minimum requirements for safe driving □ Is disqualified to drive a motor vehicle pursuant to section 391.15
□ Does not adequately meet satisfactory safe driving performance
Action taken with the driver: ______
______
Reviewed by: ______
Signature Date
TONI GEORGIEV Safety Manager______
Print Name Title
GREAT LOGISTICS EXPRESS, LLC. 7709 WALLACE STREET, MERRILLVILLE,IN 46410 .
Motor Carrier Name Motor Carrier Address
MAINTAIN THIS DOCUMENT IN THE DRIVER’S QUALIFICATION FILE. THIS DOCUMENT MAY BE PURGED AFTER 3 YEARS FROM DATE OF EXECUTION.
Company: GREAT LOGISTICS EXPRESS, LLC.
CONSENT FORM
PRE – EMPLOYMENT URINLYSIS
I understand that as required by the Federal Motor Carrier Safety Regulations Title 49 United States Code of Federal Regulations Section 391, 103, and company policy, all prospective drivers must submit to a controlled substances test. A urine sample will be collected and tested for controlled substances.
I also understand that if test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle.
The results of the drug test will be maintained by the Medical Review Officer or the company who will report whether the test results were negative or positive to the motor carrier. The results will be released to any additional parties without my written authorization. I hereby agree to submit to a drug screen – urinalysis.
Applicant’s printed nameApplicants signature Date
______
______
CERTIFICATION OF RECEIPT AND UNDERSTANDING OF
AND CONSENT TO COMPLY WITH THE COMPANY SUBSTANCE ABUSE PROGRAM
The Company is vitally concerned with those situations where the use of illegal drugs or the illegal use legal drug, and the misuse of alcohol can seriously interfere with an individuals health end job performance and The Company’s business operations, and is a hazard to the safety and welfare of other employees ot the public at lare.
The Company has established a Substance Abuse Program for the purpose of maintaining a drug and alcohol free work place, in accordance with Federal Regulation Policy.
All existing covered persons and new applicants for covered positions must be drug and alcohol free in accordance with DOT Regulations and The Company Substance Abuse Program.
I hereby certify that I have received a copy of The Company Substance Abuse Program: that I have read and understand its contents; and understand that I must be drug and alcohol free as a condition of employment.
I hereby authorize The Company to obtain my DOT drug and alcohol test results firm my past employers to the previous two (2) years, in accordance with the Federal Regulations and understand that those test results will be kept strictly confidential.
I understand The Company has designated a third party to act as its “Designated Agent” for the purpose of receiving and processing individual drug and alcohol test results administered to its employees and job applicants.
I hereby authorize The Company’s “Designated Agent” to receive my drug and alcohol test results direct from The Company’s drug testing laboratories and alcohol testing facilities and to process and report such test results to the Company in a confidential manner.
Printed name:Social Security number:
______
Signature:Date:
______
Company’s representative printed nameCompany’s representative signature
TONI GEORGIEV________
Company Name: GREAT LOGISTICS EXPRESS, LLC______
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 J, 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 employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.
______
Applicant’s signature Date
______
Print Name Social Security number
PREVIOUS PRE – EMPLOYMENT EMPLOYEE
ALCOHOL AND DRUG TESTING STATEMENT
Sec. 40.25(1) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety sensitive transportation work covered by DOT agency, drug and alcohol testing rules during the past two years. If an employee admits that he or she had a positive test or refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return to duty process. (See Section 40.25(b)(5) and (e))
TO BE READ AND SIGNED BY APPLICANT
Have you ever been tested positive or refused to be tested on any pre – employment drug test in which you were not hired during the past two years?
□ YES □ NO
If you answered YES, can you provide or obtain on our request proof that you have successfully completed the DOT return – to – duty requirements?