APPLICATION FOR QUALIFICATION


Central Carriers

2823 Hwy 2 West

Rugby, ND 58368


The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company named above.


Instructions to Applicant


Please answer all questions. If the answer to any question is “No” or “None”, do not leave the item blank, but write “No” or “None”.


Date


Name


Phone Number Emergency Phone Number


*Age Date of Birth Social Security Number

*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.


Physical Exam Expiration Date:


Current & Three Years Previous Addresses:

From To

From To

From To

From To


Have you worked for this company before?

If yes, give dates: From To

Reason for leaving?


Education History


Please choose the highest grade completed:

Grade School: College: Post-Graduate:

 


Employment History


Give a Complete Record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past ten years.


  Mo/Yr   Mo/Yr Present or Last Employer:
From To Name
Position Held Address
Reason for Leaving Phone #
Were you subject to the FMCSRs* while employed here?  
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Prt 40?


  Mo/Yr   Mo/Yr Present or Last Employer:
From To Name
Position Held Address
Reason for Leaving Phone #
Were you subject to the FMCSRs* while employed here?  
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Prt 40?


  Mo/Yr   Mo/Yr Present or Last Employer:
From To Name
Position Held Address
Reason for Leaving Phone #
Were you subject to the FMCSRs* while employed here?  
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Prt 40?


  Mo/Yr   Mo/Yr Present or Last Employer:
From To Name
Position Held Address
Reason for Leaving Phone #
Were you subject to the FMCSRs* while employed here?  
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Prt 40?


  Mo/Yr   Mo/Yr Present or Last Employer:
From To Name
Position Held Address
Reason for Leaving Phone #
Were you subject to the FMCSRs* while employed here?  
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Prt 40?


*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.



Driving Experience



Class of Equipment
Dates
Approximate Number of Miles (Total)
From
To
Straight Truck
Tractor and Semi-trailer
Tractor-two trailers
Tractor-three trailers (triples)
Other


List States operated in, for the last five years:


List special courses/training completed (PTD/DDC, Haz Mat, etc.):


List any Safe Driving Awards you hold and from whom:


Accident Record for past three years (email word document to alida@centralcarriers.com if more space is needed)

Date of Accicent
Nature of Accident
(Head on, rear end, upset, etc.)
Location of Accident
# of Fatalities
# of People Injured


Traffic Convictions and Forfeitures for the last three years (other than parking violations)

Date
Location
Charge
Penalty


Driver's License (list each driver's license held in the past three years)

State
License #
Type
Endorsements
Expiration Date
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
B. Has any license, permit or privilege ever been suspended or revoked?

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

D. Have you ever been convicted of a felony?

If the answers to A, B, C or D is "YES", give details:


Personal References


List three persons for references, other than family members, who have knowledge of your safety habits.

Name Address Phone

Name Address Phone

Name Address Phone

 

To Be Read and Signed by Applicant


It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

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.

 

Applicant Signature Date