Class A Driver Application - ValleyWideBeverage

APPLICANT INFORMATION

Name*

First Middle Last

Phone*

E-mail*

Date of Birth*

Social Security #*

Date of Application*

Position Applied For*

Applying for:*

Full-time
Seasonal

Date Available for Work*

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

Yes
No

Do you now, or will you in the future, require immigration sponsorship for work authorization (e.g., H-1B)?*

Yes
No (If hired, verification will be required consistent with federal law.)

PREVIOUS THREE YEARS OF RESIDENCY

Current Address

Address*

Street Address Address Line 2 City State ZIP Code

Number of Years at Address*

Mailing Address

Address

Street Address Address Line 2 City State ZIP Code

Number of Years at Address

Previous Address

Address

Street Address Address Line 2 City State ZIP Code

Number of Years at Address

Previous Address

Address

Street Address Address Line 2 City State ZIP Code

Number of Years at Address

Previous Address

Address

Street Address Address Line 2 City State ZIP Code

Number of Years at Address

LICENSE INFORMATION

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years.

Current License

State*

License #*

Type/Class*

Endorsement*

Expiration Date*

Previously Held License

State

License #

Type/Class

Endorsement

Expiration Date

Previously Held License

State

License #

Type/Class

Endorsement

Expiration Date

DRIVING EXPERIENCE

Straight Truck

Type of Equipment (Van, Tank, Flat, Etc.)*

Approx # of Miles (Total)*

Date From*

Date To

Tractor & Semi-Trailer

Type of Equipment (Van, Tank, Flat, Etc.)

Approx # of Miles (Total)

Date From

Date To

Other

Type of Equipment (Van, Tank, Flat, Etc.)

Approx # of Miles (Total)

Date From

Date To

ACCIDENT RECORD FOR THE PAST 3 YEARS

Check this box if none

None

Date (Most recent)

Nature of Accident (Head-on, Rear-end, Upset, etc.)

Number of Fatalities

Number of Injuries

Chemical Spills?

Yes
No

Date

Nature of Accident (Head-on, Rear-end, Upset, etc.)

Number of Fatalities

Number of Injuries

Chemical Spills?

Yes
No

Date

Nature of Accident (Head-on, Rear-end, Upset, etc.)

Number of Fatalities

Number of Injuries

Chemical Spills?

Yes
No

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

Check this box if none

None

Date Convicted

Violation

State of Violation

Penalty (Forfeited bond, collateral and/or points)

Date Convicted

Violation

State of Violation

Penalty (Forfeited bond, collateral and/or points)

Date Convicted

Violation

State of Violation

Penalty (Forfeited bond, collateral and/or points)

Date Convicted

Violation

State of Violation

Penalty (Forfeited bond, collateral and/or points)

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

Yes
No

If yes, explain:

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

Yes
No

If yes, explain:

EMPLOYMENT HISTORY

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.

Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.

Current (Most Recent) Employer

Employer Name*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Position Held*

Reason for Leaving*

From*

To*

Explain Any Gaps in Employment (Including month/year & reason)*

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*

Yes
No

Second (Most Recent) Employer

Employer Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Position Held

Reason for Leaving

From

To

Explain Any Gaps in Employment (Including month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Third (Most Recent) Employer

Employer Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Position Held

Reason for Leaving

To

From

Explain Any Gaps in Employment (Including month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Fourth (Most Recent) Employer

Employer Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Position Held

Reason for Leaving

From

To

Explain Any Gaps in Employment (Including month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

EDUCATION

High School or G.E.D. Equivalent

School Name and Location*

Course of Study or Major*

Years Completed*

Graduated?*

Yes
No

Details

College or University

School Name and Location

Course of Study or Major

Years Completed

Graduated?

Yes
No

Details

Vocational or Trade School

School Name and Location

Course of Study or Major

Years Completed

Graduated?

Yes
No

Details

Other (including military training)

School Name or Location

Course of Study or Major

Years Completed

Graduated?

Yes
No

Details

OTHER QUALIFICATIONS

Please list any other qualifications that you have and which you believe should be considered.

BACKGROUND INFORMATION

For the purpose of verifying information on this application, have you ever worked or attended school under a different name at any of the organizations you have listed?*

Yes
No

If yes, specify name

PROFESSIONAL REFERENCES

List three professional references (other than those listed as current/former supervisor) that we may contact:

Name*

Phone*

Email*

Type of Acquaintance*

Name*

Phone*

Email*

Type of Acquaintance*

Name*

Phone*

Email*

Type of Acquaintance*

Should you receive a conditional offer from the Company, a background verification inclusive of a criminal check will be performed by a third party vendor, in accordance with federal, state and local law. The Company will also perform an individualized assessment regarding your criminal check based upon the nature and gravity of the offense, time passed since the offense occurred, and the direct and adverse relationship between prospective job duties and the offense. The Company will inform you of the results and will provide you with an opportunity to respond within (5) business days. The Company reserves the right to re-evaluate your candidacy and rescind your conditional offer after you have been given a chance to respond. Should you have any questions regarding this process, contact your Recruiter.

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to:

Review information provided by current/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; and
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.

I understand, where permissible under applicable state and local law, I may be subject to a pre-employment drug test after receiving a conditional offer of employment, and must receive a negative result for illegal drugs before being permitted to commence work with the Company.

I understand, where permissible under applicable state and local law, I may be subject to a pre-employment medical examination after receiving a conditional offer of employment, and must meet the qualifications for the position, with or without reasonable accommodation, before being permitted to commence work for the Company.

I understand employment with the Company is also contingent on my providing sufficient documentation necessary to establish my identity and eligibility to work in the United States.

I understand that I will be required to possess a current and valid California driver's license and provide proof of automobile insurance if my job requires me to drive in the course of my work.

I expressly understand and agree that, if employed, my employment, having no specified term, is based upon mutual consent and may be terminated at will, with or without cause, by either party (the Company or me) without prior notice to the other, unless otherwise prohibited by law.

I understand that no representation, whether oral or written, by any representative or agent of the Company, at any time, can constitute an implied or expressed contract of employment. I further understand no representative or agent of the Company has the authority to enter into an agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other terms or condition of employment other than in a document signed by the CEO or an authorized representative.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

Applicant's Signature*

Date*

Applicant's Name (printed)*

Phone

This field is for validation purposes and should be left unchanged.