First Name: *
Last Name: *
Address: *
City: *
State: *
Zip Code: *
Telephone: *
Emergency Name: *
Emergency Number: *
Are you 18 years of age or older? *

  • Yes
  • No
Do you have the legal right to live and work in the USA? *

  • Yes
  • No
Since the age of 18, have you been convicted of a misdemeanor or felony? *

  • Yes
  • No
If so, please advise nature and date:
Have you ever worked for this company before? If so, please indicated when and position held. *
Under any other name? *

  • Yes
  • No
If so, under what name?
Do you have any relatives employed by this company? *

  • Yes
  • No
If so, please state name(s):

The following information is required by the U.S. Department of Transportation, Section 391.21. Your application will not be considered if all information is not furnished.

PREVIOUS RESIDENCYPlease furnish the addresses at which you resided during the 3 years preceding the date on which the application is submitted.
BEGIN WITH THE MOST RECENT

Address
Street
City
State
Length of Residency
COMMERCIAL MOTOR VEHICLE OPERATOR’S LICENSEPlease furnish the issuing State, number, and expiration of each unexpired commercial motor vehicle operator’s license or permit that has been issued to you in the lines provided below:
State
Number
Expiration
License/Permit
Have you ever been denied a license, permit or privilege to operate a motor vehicle? *

  • Yes
  • No
If so, please explain:
Has one ever been suspended? *

  • Yes
  • No
If so, please explain this:
Have you ever been disqualified for violation of Safety Regulations? *

  • Yes
  • No
If so, please explain
EMPLOYMENT RECORDThe U.S. Department of Transportation requires that driver applicants show all employment for the
past three years. Effective July 1987, applicants must show all commercial driver employment for the seven years immediately preceding this three year period. 391.21 (b) (10)(11)

Authorization

I authorize Interstate Freight Carriers to obtain information about me from my previous employers, schools and
credit sources. I authorize my previous employers, schools that I have attended and all credit sources to disclose to Interstate Freight Carriers such information about me as Interstate Freight Carriers may request.

Authorize IC Freight To Obtain Information: *


Yes

Are you currently employed? *

  • Yes
  • No
If so, may we contact your present employer?

  • Yes
  • No
If you are accepted for employment, when would you be available? *
Name and Address of Company
From
To
Month
Year
Month
Year
Starting Hourly Rate
Ending Hourly Rate
Reason for Leaving
Name of Supervisor
Telephone

 

Name and Address of Company
From
To
Month
Year
Month
Year
Starting Hourly Rate
Ending Hourly Rate
Reason for Leaving
Name of Supervisor
Telephone

 

Name and Address of Company
From
To
Month
Year
Month
Year
Starting Hourly Rate
Ending Hourly Rate
Reason for Leaving
Name of Supervisor
Telephone
PAST EXPERIENCEPlease list below the nature and experience in the operation of heavy equipment, including the type of
equipment (such as scrapers, backhoes, loaders, excavators, etc.) which you have operated.

Nature
(i.e. hauled construction material)
Experience
(years)
Type of Vehicle

 

MOTOR VEHICLE ACCIDENTS

Please list all of the motor vehicle accidents in which you have been involved during the 3 years preceding the date of the application.

Date
Nature
Fatalities/Personal Injuries (explain)

MOTOR VEHICLE VIOLATIONS

Please list all violations of motor vehicle laws or ordinances (other than violations involving only parking) of which you were convicted or forfeited bond or collateral during the 3 years preceding the date of the application.

Date
Nature

 

NOTICE TO APPLICANT

1.
All information submitted will be considered in reviewing my application and is subject to investigation. I hereby authorize Interstate Freight Carriers to investigate all statements applicable, except as indicated.

2.
I certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts called for is cause for dismissal upon discovery of such information.

3.
If accepted for employment, I hereby agree to comply with the rules, regulations and policies of Interstate Freight Carriers.

4.
I am aware that an investigative consumer report may be made in connection with my application for employment. This report may include information as to my character, general reputation, personal habits, and mode of living, obtained from or through personal interview with persons with whom I am acquainted, or those persons who may have knowledge concerning any such items of information.

5.
In the event that such an investigative consumer report is procured, upon my written request of Interstate Freight Carriers, I will be provided with a complete and accurate disclosure of the nature and scope of the investigation conducted.

6.
I understand that Interstate Freight Carriers follows an employment-at-will policy, in that I or Interstate Freight Carriers may terminate my employment at any time, for any reason consistent with applicable State or Federal Law.

PRE-EMPLOYMENT SUBSTANCE DETECTION CONSENT

I understand that according to the Pre-employment Substance Detection Program at Interstate Freight Carriers, I am required to submit a sample of my urine for chemical analysis prior to employment.

I understand that this pre-employment substance detection will be conducted be a reputable outside physician and testing agency by a certified laboratory.

I consent freely and voluntarily to this request for a pre-employment urine specimen. I hereby and herewith release Interstate Freight Carriers, their employees, agents, and contractors from any liability whatsoever arising form this request to furnish a pre-employment urine sample, the testing of the urine sample and decisions made concerning my application for employment or continued employment based upon the results of these tests.

I understand a positive test for controlled substances, based on the urinalysis test, will disqualify me from employment and/or the operation of a commercial motor vehicle for Interstate Freight Carriers.

I understand that if the substance detection results are positive, I can request a second independent confirmatory test using the same specimen. The cost of this test will be borne by me.

I understand a documented chain of specimen custody exists to ensure the identity and integrity of my sample throughout the collection and testing process. The Medical Review Officer will maintain the results of the urinalysis test. Negative and positive results will be reported to the company.

I understand that if my employment is terminated for any reason with Interstate Freight Carriers within 90 days, I am liable for the cost of the urinalysis, which is $40.00.


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. I have also read and understand the above Notice to the Applicant and the conditions for the Pre-Employment Urinalysis Consent Agreement.

Digital Signature Agree *

Agree

Digital Signature Name *
Digital Signature Date *
Email Address

NOTE: Failure to sign the above consent discontinues the employment process

Equal Opportunity Employer – our hiring policy is simple: We follow the law! This company hires lawful
workers only. U.S. citizens or nationals and non-citizens with valid work authorization – without discrimination.

Federal immigration law requires all employers to verify both the identity and employment eligibility of
all persons hired to work in the United States.

In its efforts to meet the law’s requirements, this company is participating in the Basic Pilot program
established by the Department of Homeland Security and the Social Security Administration (SSA) to aid employers in verifying the employment eligibility of all newly hired employees. Our participation in the pilot program does not exempt us from the obligation to complete a Form I-9 for everyone we hire.

For additional information on the verification program contact the:

Department of Homeland Security

USCIS/SAVE Program

111 Massachusetts Avenue, 2nd Floor

Washington, DC 20001 Phone (888)464-4218

Equal Opportunity Employer – nuestra póliza de empleo es simple: Nosotros seguimos la ley! Sin disriminación, esta compañia emplea solamente trabajadores legales – ciudadanos o nacionales de los Estados Unidos y extranjeros con autorización de trabajo.

La Ley Federal de Inmigración y Nacionalidad requiere que todas las empresas verifiquen la identidad y elegibilidad de las personas que buscan empleo en los Estados Unidos.

En su esfuerzo de cumplir los requisitos de la Ley, esta compañia participa en un programa Piloto Básico de verificación de empleo, establecido por El Departmento de Seguirdad Nacional en conjunto con la Administración de Seguro Social en esta forma los empleadores, verificaran la elegibilidad de todos los nuevos aplicantes. Nuestra participación en este programa piloto, hace que no exista ningun tipo de excepción en la Ley, tenemos la obligación de completar el formulario I-9 para toda persona que nostros empleamos.

Para mayor información de este programa de verificación, puede usted comunicarse:

Department of Homeland Security

USCIS/SAVE Program

111 Massachusetts Avenue, 2nd Floor

Washington, DC 20001 Phone (888)464-4218