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Driver Information
 
* Full Name  :
* Street Address :
* City :
* State :
* Zip Code :
* Day Phone Number :
* Evening Phone Number :
   Cell Phone Number :
* Best Time To Call :
   Email :
* Date of Birth :
   Age :
* SSN :
CDL Info.
CDL Number : Expiration Date
License State :

Class
Class A
Class B
Class C
Endorsements
Hazmat
Double/Triple
Tanker
Driving Experience

* What Type of Driver Are You?
 For Owner Operators:
Company Driver How Many Trucks Do You Own?
Owner Operator Truck Make:    Model: 
Student

Are You a Truck School Graduate?
Yes No
* How Many Years of Driving Experience?
Traffic Violations in the Past 3 Years
Traffic Accidents in the Past 3 Years
Work History

Current Employer
Employer Address Street / City / State / Zip
Starting Date (mm-dd-yyy)
Employer Phone Number 123-456-7890
Name of Previous Employer
Employer Address Street / City / State / Zip
Starting Date (mm-dd-yyy)
 Ending Date (mm-dd-yyy)
Employer Phone Number 123-456-7890

Previous Employer Name
Employer Address Street / City / State / Zip
Starting Date (mm-dd-yyy)
 Ending Date (mm-dd-yyy)
Employer Phone Number 123-456-7890

Previous Employer Name
Employer Address Street / City / State / Zip
Starting Date (mm-dd-yyy)
 Ending Date (mm-dd-yyy)
Employer Phone Number 123-456-7890

Previous Employer Name
Employer Address Street / City / State / Zip
Starting Date: (MM-DD-YYYY)
 Ending Date: (MM-DD-YYYY)
Employer Phone Number 123-456-7890
Criminal History
Have you ever had a Felony Conviction?
Yes | No   If so, when?  (mm-dd-yyy)

Do you have Pending DUI Charges?
Yes | No   If so, when?  (mm-dd-yyy)

Do you have any Drug Convictions?
Yes | No   If so, when?  (mm-dd-yyy)

Have you ever been denied a license or permit for operating a motor vehicle?
Yes | No   If so, when?  (mm-dd-yyy)

Has your license or permit ever been suspended/revoked?
Yes | No   If so, when?  (mm-dd-yyy)

Have you been convicted, or are there charges pending, for reckless driving or careless operation?
Yes | No   If so, when?  (mm-dd-yyy)

Have you ever been refused any type of insurance or been denied bonding?
Yes | No   If so, when?  (mm-dd-yyy)

Have you ever been discharged or suspended while working for another employer?
Yes | No   If so, when?  (mm-dd-yyy)

Comments


 

 IMPORTANT NOTICE

REGARDING BACKGROUND REPORTS

FROM THE PSP Online Service

:

In connection with your application for employment with Mad River Transportation. (“Prospective Employer”), it may obtain one or more reports regarding your credit, driving, and/or criminal background history from a consumer reporting agency and/ or other sources. If the Prospective Employer uses any information it obtains from a background report in a decision to not hire you or to make any other adverse employment decisions 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 any final adverse action. If any final adverse action is taken against you based upon a background report, the Prospective Employer will notify you that the action has been taken and the background report was the reason for the action. The Prospective Employer cannot obtain background reports from consumer reporting agencies or sources regarding you unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following.

 

I authorize Mad River Transportation (“Prospective Employer”) to contact any organization or individual that I have listed on my employment application or resume or mentioned in job interviews and obtain from them any relevant information about my job qualifications, including my experience, skills, and abilities. 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, as well as any reference-related information about me held or known by my former employers, supervisors, and co-workers. In addition, I consent to the release of any information about my education, experience, abilities, or work-related characteristics or traits held or known by other organizations or individuals, including schools and educational institutions, professional or business associates, and friends and acquaintances the Prospective Employer might contact in the course of conducting a reference check or background investigation of my suitability for employment.

 

I understand and acknowledge that this release of information can involve my qualifications, performance, credentials, or other characteristics or factors affecting my suitability for employment with Prospective Employer. Specifically, I am authorizing the release of any information about my performance, experience, capabilities, attitude, specific events, or other work-related characteristics that currently are in the possession of the requested organizations or their managers or representatives.

 

In exchange for Prospective Employer’s consideration of my employment application, I agree not to file or pursue any complaints, claims, or legal actions of any kind against any organization or individual that provides work-related information about me to Prospective Employer or its agents in accordance with the terms and intent of this release. I also agree not to file or pursue and complaints, claims or legal action against Prospective Employer or any of its employees, representatives, or agents arising out of their efforts to obtain work-related information about me.

 

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 and/or any entity it retains to obtain such background reports may obtain reports of my credit, driving, and/or criminal background history in addition to information regarding my background, references, education, specific events, and past employment.

 

By submitting this online application, I authorize Prospective Employer and its employees, agents, and affiliates to obtain the information authorized above.


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