Position(s) Applied for*

Name*

First Middle Last

Phone

Current Address

Street

City

State & Zip Code

How long?*

yr./mo.

Previous addresses. List your addresses of residency for the past 3 years.

Street

City

State & Zip Code

How long?

yr./mo.

Do you have the legal right to work in the United States?*

Date of Birth

MM

DD

YYYY

Required for Commercial Drivers

Can you provide proof of age?*

Have you work for this company before?*

Where?

FROM

TO

Rate of Pay

Position

Reason for Leaving

Are you now Employed?*

How long since last employment

Who referred you?

Rate of pay expected?

Have you ever been bonded?

Answer only if a job requirement

Name of bonding company?

Can you perform, with or without reasonable accommodation, the essential functions of the job.*

Employment History

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

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Contact person

Phone

From

To

Position Held

Salary/Wage

Reason for Leaving

Where you subject to the FMCSRs while employed?

Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CPR part 40?

Click the "+" to add another

Accident Record

Accident Record for past 3 years or more.

Did you ever had any accident record?

Yes
No

Date

Nature of Accident

Head-on, Rear-end, Upset, Etc.

Fatalities

Yes
No

Injuries

Yes
No

Hazardous Material Spill

Click the "+" to add another accident

Traffic Convictions

Traffic Convictions and forfeitures for past 3 years or more. (other than parking violations).

Did you ever had any traffic convictionsand forfeitures?

Yes
No

Location

Date

Charge

Penalty

Click the "+" to add another

Experience and Qualifications - Driver

State

License No.

Class

Endorsements(s)

Expiration date

Click the "+" to add another

Have you ever been denied a license, permit or privilege to operate a motor vehicule?

Yes
No

Please give us more details

Has any license, permit or privilege ever been suspended or revoked?

Yes
No

Please give us more details

Driving Experience

Straight truck

Yes
No

Circle type of equipment

Van
Tank
Flat
Dump
Refer

From

To

Approx. No. of Miles (TOTAL)

Tractor and semi-trailer

Yes
No

Circle type of equipment

Van
Tank
Flat
Dump
Refer

From

To

Approx. No. of Miles (TOTAL)

Tractor - two trailers

Yes
No

Circle type of equipment

Van
Tank
Flat
Dump
Refer

From

To

Approx. No. of Miles (TOTAL)

Tractor - three trailers

Yes
No

Circle type of equipment

Van
Tank
Flat
Dump
Refer

From

To

Approx. No. of Miles (TOTAL)

Motorcoach - School Bus, More than 8 passengers

Yes
No

From

To

Approx. No. of Miles (TOTAL)

Motorcoach - School Bus, More than 16 passengers

Yes
No

From

To

Approx. No. of Miles (TOTAL)

Other

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 that those already shown)

Education

Highest grade completed

Last school attended (name) / (City-State)

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

In connection with your application for employment with Global Transportation USA 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 Global Transportation USA 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.

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.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49
C.F.R. 383.5.

LAST UPDATED 12/22/2015

DISCLOSURE AND AUTHORIZATION*

I Agree

Date*

Name*

Apply Now!

Driver’s Application independent contractor

Current Address

Previous addresses. List your addresses of residency for the past 3 years.

Employment History

Accident Record

Traffic Convictions

Experience and Qualifications - Driver

Driving Experience

Experience and qualifications - Other

Education

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

AUTHORIZATION