Online Application

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Online Application

Section 2: Authorization to obtain background information

SSN #:

This field is required

ssn value should be numeric

Referred By:

If your current address is less than three years old, Please list the previous address directly below it:

1 Street:

Dates: From:

City:

State:

Zip:

To:

2 Street:

Dates: From:

City:

State:

Zip:

To:

Driver License Information:all licences held. last three years

State License # Type Expires

Drivers Licenses

Do you have the legal right to work in the U.S.?

YesNo

Are you presently working?

YesNo

If not, how long since last job?

QUALIFICATIONS

Do you have any physical conditions which may limit your ability to perform the job of an OTR Reefer Driver?

YesNo

Please explain

Have you ever tested positive for drugs or alcohol as a commercial driver?

YesNo

If yes, when?

Please explain

Have you successfully completed the return �to- duty process?* *You must provide documentation before hiring can be completed.

YesNo

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

YesNo

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

YesNo

Do you have more than one moving violation in the last three years?

YesNo

Hazmat Endorsement

YesNo

TWIC Card

YesNo

Date of Last Accident

Have you ever convicted for possession, sale or use of a controlled substance?

YesNo

Date

Have you ever convicted of driving under the influence?

YesNo

Date

Have you ever convicted of a Felony?

YesNo

Date

How many at fault road side inspection violations have you had in the past year

How many were log violations?

EXPERIENCE

Type of Vehicle Driven

Dates (From / To)

Approximate Mileage

Commercial Driver Since

Years of Commercial vehicle experience

Years of Reefer trailer operation:

DRIVER WORK HISTORY

Starting with the most recent employer, please provide 10 years of work history. All gaps must be noted with the dates and reason an employer is not listed.

Date: From:

To:

Unemployed

Self-Employed

Worked for a Company

Were you regulated under FMCSA rules?

Yes No

Were you subject to Drug and Alcohol testing?

Yes No

Company

Position Held

Reason for Leaving

Address

Contact Person

Phone Number

Date: From:

To:

Unemployed

Self-Employed

Worked for a Company

Were you regulated under FMCSA rules?

Yes No

Were you subject to Drug and Alcohol testing?

Yes No

Company

Position Held

Reason for Leaving

Address

Contact Person

Phone Number

Date: From:

To:

Unemployed

Self-Employed

Worked for a Company

Were you regulated under FMCSA rules?

Yes No

Were you subject to Drug and Alcohol testing?

Yes No

Company

Position Held

Reason for Leaving

Address

Contact Person

Phone Number

Date: From:

To:

Unemployed

Self-Employed

Worked for a Company

Were you regulated under FMCSA rules?

Yes No

Were you subject to Drug and Alcohol testing?

Yes No

Company

Position Held

Reason for Leaving

Address

Contact Person

Phone Number

Date: From:

To:

Unemployed

Self-Employed

Worked for a Company

Were you regulated under FMCSA rules?

Yes No

Were you subject to Drug and Alcohol testing?

Yes No

Company

Position Held

Reason for Leaving

Address

Contact Person

Phone Number

Date: From:

To:

Unemployed

Self-Employed

Worked for a Company

Were you regulated under FMCSA rules?

Yes No

Were you subject to Drug and Alcohol testing?

Yes No

Company

Position Held

Reason for Leaving

Address

Contact Person

Phone Number

Please list all accidents involved in (at fault or not) for the prior 3 years.

Date

Type of Accident

Fatalities

Injuries

Accident #1

Accident #2

Accident #3

Please list all traffic convictions and forfeitures for the past 3 years (other than parking violations)

Location

Date

Charge

Penalty

For as long as I am operating for Hickory Transportation Services (HTS), I the undersigned, have authorized HTS and their affiliates/agents/representatives, to obtain the following information:

Past employment references (skills, behavior, experience, drug & alcohol tests) (391.23)
Driving record history
Criminal background records

I understand that any information obtained as a result of this release will be provided to HTS for hiring eligibility based on DOT regulations under part 391 of 49 CFR.

Driver Name

SSN #

CDL #

Address

City

State

Zip

I Accept

Please check this box if want to proceed.

Thank You

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