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Driver Application Request

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Refrigerated Transportation

P.O. Box 831 – Huron, SD 57350

(605) 352-8404

Fax: 1-605-352-1876

DRIVER’S

APPLICATION FOR EMPLOYMENT

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, or non-job related disability.

Position(s) Applied for:*

Date of Application:

Name:*

First Name Middle Last

Social Security Number:

List your addresses of residency for the past 3 years.

Current Address:

Street City State Zip

Phone:*

How long?

Previous Addresses:

Street City State Zip

How long?

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

Date of Birth*

(Required for Commercial Drivers License)

Can you provide proof of age?

Have you worked for this company before?

Where?

Dates: From

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:

Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the attached job description)?

If yes, explain:

Employment History

Must show the previous 10 years

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 10 years. List complete mailing address, street number, city, state, and zip code.

NOTE: List employers in reverse order starting with the most recent first. Add additional sheets as needed, just print multiple copies of this page.

EMPLOYER

Name:*

Address:*

City State Zip

Contact Person:

Phone Number:*

Reason for Leaving:*

DATE

From

Position:

Salary:

EMPLOYER

Name:

Address:

City State Zip

Contact Person:

Phone Number:

Reason for Leaving:

DATE

From

Position:

Salary:

EMPLOYER

Name:

Address:

City State Zip

Contact Person:

Phone Number:

Reason for Leaving:

DATE

From

Position:

Salary:

EMPLOYER

Name:

Address:

City State Zip

Contact Person:

Phone Number:

Reason for Leaving:

DATE

From

Position:

Salary:

EMPLOYER

Name:

Address:

City State Zip

Contact Person:

Phone Number:

Reason for Leaving:

DATE

From

Position:

Salary:

EMPLOYER

Name:

Address:

City State Zip

Contact Person:

Phone Number:

Reason for Leaving:

DATE

From

Position:

Salary:

Accident record for the past 3 years of more (attach additional sheets if needed). If none, write “NONE”.

Dates

Last:

Nature of Accident (head-on, rear-end, upset, etc.)

Fatalities

Injuries

Nature of Accident (head-on, rear-end, upset, etc.)

Fatalities

Injuries

Nature of Accident (head-on, rear-end, upset, etc.)

Fatalities

Injuries

Traffic convictions and forfeitures for the past 3 years (other than parking violations.) If none write “NONE”. Attach additional sheets if needed.

Location

Date

Charge

Penalty

EDUCATION

Circle highest grade completed:

High School:

College:

Last school attended:

Name

City State

Experience and Qualifications – Driver

Driver Licenses

State

License No

Type

Expiration Date

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

Yes

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

Yes

If the answer to either of the above two questions was yes, attach statement giving details.
Driving Experience: If none, write “NONE”

Class of Equipment

Type of Equipment (van, tank, flat, etc.)

Date From

Date To

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):

TO BE READ AND SIGNED BY APPLICANT
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 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 even 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.

Date

Applicant’s Signature

Max. file size: 1 GB.

Upload Signature

PROCESS RECORD

Applicant hired:

Rejected:

Date Employed:

Point Employed:

Department:

(If rejected, summary report of reasons should be placed in file.)

Classification:

This section to be filled in by responsible officer or company representative.

Application

Interview

Past Employment

Written Exam

Road Test

Criminal and Traffic Convictions

Signature of Interviewing Officer:

Max. file size: 1 GB.

Upload Signature

TRANSFERS

From:

Date:

Reason for Transfer:

From:

Date:

Reason for Transfer:

From:

Date:

Reason for Transfer:

From:

Date:

Reason for Transfer:

TERMINATION OF EMPLOYMENT

Date Terminated:

Department Released From:

Dismissed

Voluntarily Quit:

Other:

Termination Report Placed in File:

Supervisor:

Release & documentation of testing information by previous employer

Date of driver’s employment application:

Part 1 – To be completed by driver/applicant.

, hereby authorize

to release to

Address

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

results of any verified positive drug tests; alcohol tests with a result of 0.04 or greater, evidence of refusal to be tested (including verified adulterated or substituted drug test results); other violations of DOT agency drug and alcohol testing regulations; and information on any required substance abuse professional (SAP) evaluation, determination of need for assistance, and compliance with SAP recommendations. The information obtained from a previous employer includes any drug or alcohol test information obtained from previous employe rs under applicable DOT agency regulations. I request such records be released immediately.

Dated this

day of

Name of driver

Signature of driver

Max. file size: 1 GB.

Upload Signature

Social Security Number

Witness

Part 2 – To be completed by previous employer.

1. Has this person ever tested positive for controlled substances under Part 382 during employment with your company?

Yes

2. Has this person ever had an alcohol test with a result of 0.04 or greater under Part 382 during employment with your company?

Yes

3.Has this person ever refused a required test for drugs or alcohol under Part 382 during employment with your company?

Yes

4. Has the individual violated other DOT drug/alcohol regulations?

Yes

5. Have you received information from a previous employer that this individual violated DOT drug and alcohol regulations?

Yes

If YES to any of the above questions, please release any documentation relating to the SAP evaluation, determination, and compliance, and give the SAP’s name, address, and phone number for further reference.

SAP name

SAP phone

SAP address

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

Name of person releasing information

Date

Signature of person releasing information

Max. file size: 1 GB.

Upload Signature

REQUEST FOR INFORMATION
From Previous Employer

I hereby authorize you to release the following information to NTA, LTD.for the purpose of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.

Date

Applicant’s Signature

Max. file size: 1 GB.

Upload Signature

MAIL OR FAX TO:

PLEASE FAX BACK TO 605-352-1876

Dear/Madam:
The below named individual has made application to this company for a position as driver and states that he/she was employed by you as a driver

from

We appreciate your time in completing, in confidence, the information requested below. Thank you for your courtesy.
Sincerely,

Name of Applicant:

Social Security No.:

1. Employed from

at wage or salary of

2. Did he/she drive motor vehicle for you?

Straight Truck?

Tractor-Semitrailer?

Bus?

Other (Specify)

3. Was he/she a safe and efficient driver?

4. Reason for leaving your employ:

Discharged

Resignation

Lay Off

Military Duty

5. Was his/her general conduct satisfactory?

6. Please advise history of past driving record if available for past three years

Start Your Application, Drive Forward

Driver Application Request

DRIVER’S

APPLICATION FOR EMPLOYMENT

Employment History

EMPLOYER

DATE

EMPLOYER

DATE

EMPLOYER

DATE

EMPLOYER

DATE

EMPLOYER

DATE

EMPLOYER

DATE

EDUCATION

Driver Licenses

TERMINATION OF EMPLOYMENT

Release & documentation of testing information by previous employer

REQUEST FOR INFORMATION From Previous Employer

REQUEST FOR INFORMATION
From Previous Employer