Driver’s Application « Smith Bros Trucking

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

Driver's Application for Employment

Step 1 of 4

25%

Date*
Position(s) Applied for*
Name
First Last
Social Security Number*
Phone*
Email
Current Address*
Street Address City State ZIP Code
How long at current address*
Previous Address 1*
Street Address City State ZIP Code

List your address of residency for the past 3 years.
How long at address 1*
Previous Address 2
Street Address City State ZIP Code
How long at address 2
Previous Address 3
Street Address City State ZIP Code
How long at address 3
Do you have the legal right to work in the United States?*
Date of Birth*
Required for Commercial Drivers
Can you provide proof of age?*
Have you worked for this company before?*
Where?
Dates
Rate of Pay
Position
Reason for leaving
Are you now employed?*
If not, how long since leaving last employment?
Who referred you?*
Rate of pay expected?*
Have you ever been bonded?
Answer only if a job requirement
Name of bonding company
Have you ever been conviced of a felony?*
If yes, please explain

Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.
Is there any reason you might be unable to perform the functions of the job for which you have applied? If yes, please explain.

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.

(NOTE: List employers in reverse order starting with the most recent.)
Employer 1 Name*
Employer 1 Address*
Street Address City State ZIP Code
Contact Person at Employer 1*
Employer 1 Phone
Dates Worked at Employer 1*
FROM month/year - TO month/year
Position Held at Employer 1*
Salary/Wage at Employer 1*
Reason for Leaving Employer 1*
Employer 2 Name*
Employer 2 Address*
Street Address City State ZIP Code
Contact Person at Employer 2*
Employer 2 Phone
Dates Worked at Employer 2*
FROM month/year - TO month/year
Position Held at Employer 2*
Salary/Wage at Employer 2*
Reason for Leaving Employer 2*
Employer 3 Name
Employer 3 Address
Street Address City State ZIP Code
Contact Person at Employer 3
Employer 3 Phone
Dates Worked at Employer 3
FROM month/year - TO month/year
Position Held at Employer 3
Salary/Wage at Employer 3
Reason for Leaving Employer 3
Employer 4 Name
Employer 4 Address
Street Address City State ZIP Code
Contact Person at Employer 4
Employer 4 Phone
Dates Worked at Employer 4
FROM month/year - TO month/year
Position Held at Employer 4
Salary/Wage at Employer 4
Reason for Leaving Employer 4
*Includes vehicles having GVWR of 26.001 lbs or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

Accident Record for Past 3 Years or More
If none, write NONE.
Date of last accident
Nature of accident

(head-on, rear-end, upset, etc). List any fatalities or injuries.
Date of next previous accident
Nature of next previous accident

(head-on, rear-end, upset, etc). List any fatalities or injuries.
Traffic Convictions and Forfeitures for Past 3 Years
(Other than parking violations). If none, write NONE.
Date of last traffic conviction/forteiture
Describe the Location, Charge and Penalty
Date of next previous traffic conviction/forteiture
Describe the Location, Charge and Penalty
Education
Highest Grade Completed*
Last school attended*
Name and City
Experience and Qualifications - Driver
List Driver Licenses*

Include State, License No, Type and Expiration Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
Has any license, permit or privilege ever been suspended or revoked?*
If you answered yes to either of the above 2 questions, please give details.
Driving Experience
Straight Truck
If yes, provide details

List Type of Equipment (Van, Tank, Flat, etc), From-To Dates and Approx. No. of Miles (total)
Tractor and Semi-Trailer
If yes, provide details

List Type of Equipment (Van, Tank, Flat, etc), From-To Dates and Approx. No. of Miles (total)
Tractor - Two Trailers
If yes, provide details

List Type of Equipment (Van, Tank, Flat, etc), From-To Dates and Approx. No. of Miles (total)
Motorcoach - School Bus
If yes, provide details

List Type of Equipment (Van, Tank, Flat, etc), From-To Dates and Approx. No. of Miles (total)
Other
If yes, provide details

List Type of Equipment (Van, Tank, Flat, etc), From-To Dates and Approx. No. of Miles (total)
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 in this application
List special equipment or technical materials you can work with (other than those already shown)
Addendum to Employment Application
As a prospective employer, we must ask any applicant for a driving position with our company whether he/she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the applicant applied for, but did not obtain, "safety-sensitive transportation work" (driving a commercial motor vehicle) during the past two years.
Drug Test*
DOT regulations prohibit our utilizing you to perform a "safety-sensitive function" (driving a commercial motor vehicle) if you admit that you had a positive test, or refusal to test, until and unless you provide documents showing successful completion of a return-to-duty process in accordance with DOT regulations.
By Submitting the Application You Agree to the Following
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.

This certifies that I completed this addendum to the employment application, and that all information therein is true and complete to the best of my knowledge. I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

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 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 the company.
ELECTRONIC SIGNATURE*
PLEASE TYPE YOUR FIRST AND LAST NAME
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
*
- I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance
Date*
APPLICATION RELEASE FORMS
Applicant's Name*
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.
Fair Credit Reporting and 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 I 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 for employment purposes. These reports are required by Sections 382.413, 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. 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, inquires 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 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 also understand 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 employers will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d)&(e).

I understand 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 resend the corrected information to the prospective employer.
-Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
ELECTRONIC SIGNATURE*
PLEASE TYPE YOUR FIRST AND LAST NAME
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
*
- I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance
Date*
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS
IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Smith Brothers Trucking, Inc. (“Prospective Employer”), 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 https://dataqs.fmcsa.dot.gov. 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 Smith Brothers Trucking, 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 https://dataqs.fmcsa.dot.gov. 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 DataQs 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 appear on 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.
ELECTRONIC SIGNATURE*
PLEASE TYPE YOUR FIRST AND LAST NAME
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
*
- I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance
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.
General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse Effective January 6, 2020
I hereby provide consent to Smith Brothers Trucking, Inc. to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. This is required as part of the pre-employment background checks and a minimum of at least one year for existing drivers. The annual query will be pulled the same time as yearly MVR’s.

I understand that if the limited query conducted by Smith Brother’s Trucking, Inc. indicated that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Smith Brother’s Trucking, Inc. without first obtaining additional specific content from me.

I further understand that if I refuse to provide consent for Smith Brother’s Trucking, Inc. to conduct a limited query of the Clearinghouse, Smith Brother’s Trucking, Inc. must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.
ELECTRONIC SIGNATURE*
PLEASE TYPE YOUR FIRST AND LAST NAME
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
*
- I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance
Date*

Smith Bros Trucking – Bardstown, KY

Driver’s Application

Driver's Application for Employment

Step 1 of 4

Accident Record for Past 3 Years or More

Traffic Convictions and Forfeitures for Past 3 Years

Education

Experience and Qualifications - Driver

Driving Experience

Experience and Qualifications - Other

Addendum to Employment Application

By Submitting the Application You Agree to the Following

APPLICATION RELEASE FORMS

Fair Credit Reporting and Disclosure Statement

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse Effective January 6, 2020

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