Date: Position applying for: Rate of pay expected: First Name: Last Name: SSN: Date of birth:

List your addresses of residency for the past three years:

Current Address:

Address: City: ST: Zip: Phone: Cell: How Long?

Previous Addresses:

Address: City: ST: Zip: Phone: How Long? Address: City: ST: Zip: Phone: How Long? Address: City: ST: Zip: Phone: How Long? Do you have the legal right to work in the United States? YesNo Can you provide proof of age? YesNo Are you currently Employed? YesNo Referred by: If No, how long since leaving last employment?

Is there any reason why you might be unable to perform the functions of the job for which you are applying; as noted in the job descrition supplied?

YesNo   If, yes explain below:

Company: From: To: Address: Position Held: City: ST: Zip: Salary/Wage: Contact Person: Reason for leaving: Phone: Fax: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR's while employed/leased by this company? YesNo

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Company: From: To: Address: Position Held: City: ST: Zip: Salary/Wage: Contact Person: Reason for leaving: Phone: Fax: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR's while employed/leased by this company? YesNo

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Company: From: To: Address: Position Held: City: ST: Zip: Salary/Wage: Contact Person: Reason for leaving: Phone: Fax: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR's while employed/leased by this company? YesNo

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Company: From: To: Address: Position Held: City: ST: Zip: Salary/Wage: Contact Person: Reason for leaving: Phone: Fax: Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo Were you subject to the FMCSR's while employed/leased by this company? YesNo

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Company: From: To:

 

Address: Position Held:

 

City: ST: Zip: Salary/Wage:

 

Contact Person: Reason for leaving:

 

Phone: Fax:

 

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo

 

Were you subject to the FMCSR's while employed/leased by this company? YesNo

 

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Company: From: To:

 

Address: Position Held:

 

City: ST: Zip: Salary/Wage:

 

Contact Person: Reason for leaving:

 

Phone: Fax:

 

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo

 

Were you subject to the FMCSR's while employed/leased by this company? YesNo

 

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Company: From: To:

 

Address: Position Held:

 

City: ST: Zip: Salary/Wage:

 

Contact Person: Reason for leaving:

 

Phone: Fax:

 

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo

 

Were you subject to the FMCSR's while employed/leased by this company? YesNo

 

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Company: From: To:

 

Address: Position Held:

 

City: ST: Zip: Salary/Wage:

 

Contact Person: Reason for leaving:

 

Phone: Fax:

 

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo

 

Were you subject to the FMCSR's while employed/leased by this company? YesNo

 

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Company: From: To:

 

Address: Position Held:

 

City: ST: Zip: Salary/Wage:

 

Contact Person: Reason for leaving:

 

Phone: Fax:

 

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo

 

Were you subject to the FMCSR's while employed/leased by this company? YesNo

 

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Company: From: To:

 

Address: Position Held:

 

City: ST: Zip: Salary/Wage:

 

Contact Person: Reason for leaving:

 

Phone: Fax:

 

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo

 

Were you subject to the FMCSR's while employed/leased by this company? YesNo

 

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Company: From: To:

 

Address: Position Held:

 

City: ST: Zip: Salary/Wage:

 

Contact Person: Reason for leaving:

 

Phone: Fax:

 

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo

 

Were you subject to the FMCSR's while employed/leased by this company? YesNo

 

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Company: From: To:

 

Address: Position Held:

 

City: ST: Zip: Salary/Wage:

 

Contact Person: Reason for leaving:

 

Phone: Fax:

 

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? YesNo

 

Were you subject to the FMCSR's while employed/leased by this company? YesNo

 

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Add More Employers

 

Have you had any accidents in the past three or more years? YesNo   If, yes please list them below (most recent first): Date: Nature of Accident: Fatalities: Injuries:       Traffic convictions and forfeitures for the past 3 years (Other than parking violations) Location: Date: Charge: Penalty:         Education Highest grade completed: Last school attended: Experience and Qualifications - Driver State: License #: Type: Expiration Date:     Have you ever been denied a license, permit or privilege to drive? YesNo Has any license, permit, or privilege ever been suspended or revoked? YesNo Have you ever been convicted of a Felony, DUI, or DWI? YesNo Driving Experiance Class of Equipment: Type: Dates: Approximate # of Miles:   (Van,Flat,Tank) From                        To   Straight Truck Tractor and Trailer Tractor - Doubles Motor coach - School Bus Other

List the States operated in for the last five years:

List special courses or training that will help you as a driver:

List safe driving awards earned:

 

Experience and Qualifications - Other

Show any trucking, transportation, or other experience that may help you in your work with the company:

List courses and training other than shown elsewhere in this application:

List special equipment or technical materials you can work with:

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 authorize you to make such investigations and inquiries of my personal, employment, financial, 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 after 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 inquiries 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 Bell Logistics, Inc.

By typing your name in the signature field, you agree that this electronic signature is the legal equivalent of your manual signature and is legally binding. You may opt out of electronically signing by leaving the signature field blank. By opting out you will need to come in and sign the documents manually to continue the employment process.

Signature: Date:

Fair Credit Reporting Act Disclosure Statement

In accordance with the provision 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 1, 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.

Driver Notification

This notice serves to fulfill the requirements of 49 CFR Part 391.239(i). Each motor carrier must notify each driver, who is regulated by the Department of Transportation, of their rights regarding investigative information that will be provided to a prospective employer.

Drivers have:

  - The right to review information provided by previous employers;

  - The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer;

  - The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

 

Disclosure and Release

In connection with my application for employment (including contract for services) with you, I understand that consumer reports which may contain public record information may be requested from DAC Services, Tulsa, OK and/or Fleetwatch, Denver, CO. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers’ compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state, and other agencies which maintain such records; as well as information from DAC/Fleet Watch concerning previous driving record requests made by others from such state agencies, and state provided driving records.

I authorize, without reservation, any party or agency contacted by DAC/Fleetwatch to furnish the above mentioned information.

I have the right to make a request to DAC/Fleetwatch, 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 DAC/Fleetwatch has previously furnished within the two-year period preceding my request. I hereby consent to your obtaining the above information from DAC/Fleetwatch; and I agree that such information, which DAC/Fleetwatch has or obtains, and my employment history with you if I am hired, will be supplied by DAC/Fleetwatch to other companies, which subscribe to DAC/Fleetwatch services.

I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

Print Name: SSN:

By typing your name in the signature field, you agree that this electronic signature is the legal equivalent of your manual signature and is legally binding. You may opt out of electronically signing by leaving the signature field blank. By opting out you will need to come in and sign the documents manually to continue the employment process.

Signature: Date of Birth: Signature Date:  

Certification of Compliance with Driver's License Requirements

Per Parts 383 and 391 of the Federal Motor Carrier Safety Regulations (FMSCR) drivers of commercial motor vehicles, whether operated intrastate or interstate, may:

Possess only one license. As a commercial vehicle driver, you many not possess more than one motor vehicle license. If you have more than one license, keep the license from your state of residence and return the additional license(s) to the states that issued them. Destroying a license does not close the record in the state that issued it. Drivers must notify the state. If a multiple license has been lost, stolen, or destroyed, close your driving record by notifying the state of issuance that you no longer want to be licensed by that state.

Sections 392.42 and 393.33 of the FMSCR require that you notify your employer no later than 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 the employing motor carrier, and to 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.

Additionally, Ohio law requires that you obtain an Ohio CDL within 30 days of establishing residency in the state. You must surrender your out-of-state license to the Ohio BMV and take whatever additional testing necessary to convert your out-of-state license to an Ohio CDL.

Driver Name: Date: License #: Issuing State:

By typing your name in the signature field, you agree that this electronic signature is the legal equivalent of your manual signature and is legally binding. You may opt out of electronically signing by leaving the signature field blank. By opting out you will need to come in and sign the documents manually to continue the employment process.

Signature:  

Certification of Violations
Annual Review of Driving Records

Pursuant to FMSCR Section 391.27 each driver shall furnish information regarding any violations received during the previous 12 month period; regardless of whether these violations are in a non-CMV or CMV.

I certify that the following is a true and complete list of traffic violations required to be listed for which I have been convicted , forfeited bond, or collateral during the past 12 months.

Name of Driver: SSN: License #: Expires on: Have you had any convictions, forfeited bonds, or collateral during the past 12 months? YesNo   If, yes please list them below: Date: Offense: Location: Type of vehicle operated:            

By typing your name in the signature field, you agree that this electronic signature is the legal equivalent of your manual signature and is legally binding. You may opt out of electronically signing by leaving the signature field blank. By opting out you will need to come in and sign the documents manually to continue the employment process.

Signature: Date of Certification:  

Disclosure of past drug and alcohol test results and/or issues

Sec. 40.25(j) As an employer, we must also ask prospective employees whether he/she have tested positive, or refused to test, on any pre-employment drug or alcohol tests administered by an employer to which the you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past three years. If you, the prospective employee, admits that he/she had a positive test or a refusal to test, we must not use you to perform safety-sensitive functions for Bell Logistics Inc., until and unless you the prospective employee documents successful completion of the return-to-duty process. (see Sec. 40.25(b)(5) and (e))

Have you ever tested positive for drugs and/or alcohol in the past two years?

YesNo   If yes, explain why, when, and where this occurred:

If you anwsered yes to the previous question, were you referred to a Substance Abuse Professional(SAP)?

YesNo   If yes, provide the name, address, phone number, and dates you were seen by the SAP: Name: Date of service provided: Address: Date released to return to work: City: ST: Zip: Phone:

Have you ever refused a required test for drugs or alcohol in the past two years?

YesNo   If yes, explain why, when, and where this occurred:

You are advised that Bell Logistics, Inc. will make inquires with all employers listed per the regulatory requirements in qualifying a driver to operate a CMV. Any falsification of the above information may be grounds for refusal to employ or, if already in our employment, may be grounds for immediate termination.

I hereby acknowledge that I am providing accurate responses for the above requested information and understand that any false statements may be grounds for refusal to employ or, if already in our employment, may be grounds for immediate termination.

Applicant's Name:

By typing your name in the signature field, you agree that this electronic signature is the legal equivalent of your manual signature and is legally binding. You may opt out of electronically signing by leaving the signature field blank. By opting out you will need to come in and sign the documents manually to continue the employment process.

Signature: Date:  

Past employment safety history request

I, the listed applicant below, hereby authorize the following company(s) to release all records of employment, including assessments of my job performance, ability, fitness and drug testing results to Bell Logistics, Inc. I hereby release this company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing the following information to the above-mentioned company. The applicant’s signature on this form releases all liability of you and your company. Information is being requested in accordance with 49 CFR Parts 40, 382, and 391.

By typing your name in the signature field, you agree that this electronic signature is the legal equivalent of your manual signature and is legally binding. You may opt out of electronically signing by leaving the signature field blank. You will then need to come in and sign the documents manually to continue the employment process.

Signature: Date:  

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

1. In connection with your application for employment with Bell Logistics, 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.

The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing.

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

2. I authorize Bell Logistics 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 consenting to 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.

3. 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 https://dataqs.fmcsa.dot.gov. If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

4. Please note: 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 FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

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I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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.

By typing your name in the signature field, you agree that this electronic signature is the legal equivalent of your manual signature and is legally binding. You may opt out of electronically signing by leaving the signature field blank. By opting out you will need to come in and sign the documents manually to continue the employment process.

Signature: Date: Print Name: