Download Application for Authorization to Drive

Norsemen Trucking Inc.
106 East Main Street
Lake Mills, Iowa 50450
Telephone: 641-592-5060 Fax: 641-592-5066
Applications are held for 90 days. Applications are considered for position without regard to race, creed, color, sex,
religion, age (other than minimum requirements), disability, marital status or national origin
Application for Authorization to Drive
Please print plainly in ink and all blanks must be completed
Date of Application:___/___/___ Home Phone #: ( )_________ Alt. Phone #: (__)__________
Position Applied for: ____ Company Driver ____Contractor ____Driver for Contractor
____Full-time ____Part-time (Specify what days and hours)____________________________
Name:___________________________________________/______________________________________________
First
Middle
Last
Pr eviously Used Names
Address:_______________________________________________________________________________________
Street
City
State
Zip
How Long?
Current Address:_______________________________________________________________________________
Street
City
State
Zip
H ow Long?
List all Previous addresses for past 5 years:
_______________________________________________________________________________
_____________________________________________________
Street
City
State
Zip
How Long?
_______________________________________________________________________________
_____________________________________________________
Street
City
State
Zip
How Long?
SS#____/___/______ Drivers License#______________________ State_________ Class______
Date of Birth:___/___/___ (if you are applying for a job as a commercial truck driver.)
Incase of an emergency, whom should we contact?
________________________________________________________________________________________________
Name
Phone Number
Relationship
________________________________________________________________________________________________
Name
Phone Number
Relationship
Have you ever failed or refused a pre-employment drug/alcohol test given by a company where
you never accepted employment? Yes_____ No_____
Have you worked for this company before? Yes_____ No_____
Dates:________________
Reason for leaving: ______________________________________________________________
Did you have any relatives working for this company? Yes______ No______ If yes to this
answer:
Name:___________________________________________________Relationship:___________
EMPLOYMENT RECORD FOR THE PAST TEN (10) YEARS
Begin with your present or most recent job and work backward in order, listing your employers for at least
10 years including all full and part time employment. All times must be accounted for including military
service, self-employment and periods of unemployment. Use supplementary sheet if necessary.
WE MUST HAVE TELEPHONE NUMBERS. INCLUDE PERIODS OF UNEMPLOYMENT
Are you presently employed? ____Yes ____No
May we contact your current Employer? ____Yes ____No
Previous Employer
Dates of
Employment:
Name:_____________________________ Supervisor:__________________________
Address:__________________________________ Telephone:___________________
City:____________________________State:__________ Zip Code:_______________
To:_____________
Position Held:______________________________Rate of Pay: __________________
From:___________
Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West
___ Northwest
___ Mountains
Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump
___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____
Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________
Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________
______________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No
Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing?
Yes ___No
2nd to last Employer
Dates of
Employment:
Name:_____________________________ Supervisor:__________________________
Address:__________________________________ Telephone:___________________
City:____________________________State:__________ Zip Code:_______________
To:_____________
Position Held:______________________________Rate of Pay: __________________
From:___________
Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West
___ Northwest
___ Mountains
Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump
___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____
Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________
Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________
______________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No
Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing?
Yes ___No
3rd to last Employer
Dates of
Employment:
Name:_____________________________ Supervisor:__________________________
Address:__________________________________ Telephone:___________________
City:____________________________State:__________ Zip Code:_______________
To:_____________
Position Held:______________________________Rate of Pay: __________________
From:___________
Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West
___ Northwest
___ Mountains
Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump
___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____
Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________
Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________
______________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No
Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing?
Yes ___No
________________________________________________________________________________________________
4th to last Employer
Dates of
Employment:
Name:_____________________________ Supervisor:__________________________
Address:__________________________________ Telephone:___________________
City:____________________________State:__________ Zip Code:_______________
To:_____________
Position Held:______________________________Rate of Pay: __________________
From:___________
Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West
___ Northwest
___ Mountains
Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump
___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____
Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________
Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________
______________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No
Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing?
Yes ___No
5th to last Employer
Dates of
Employment:
Name:_____________________________ Supervisor:__________________________
Address:__________________________________ Telephone:___________________
City:____________________________State:__________ Zip Code:_______________
To:_____________
Position Held:______________________________Rate of Pay: __________________
From:___________
Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West
___ Northwest
___ Mountains
Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump
___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____
Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________
Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________
______________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No
Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing?
Yes ___No
________________________________________________________________________________________________
6th to last Employer
Dates of
Employment:
Name:_____________________________ Supervisor:__________________________
Address:__________________________________ Telephone:___________________
City:____________________________State:__________ Zip Code:_______________
To:_____________
Position Held:______________________________Rate of Pay: __________________
From:___________
Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West
___ Northwest
___ Mountains
Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump
___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____
Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________
Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________
______________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No
Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing?
Yes ___No
7th to last Employer
Dates of
Employment:
Name:_____________________________ Supervisor:__________________________
Address:__________________________________ Telephone:___________________
City:____________________________State:__________ Zip Code:_______________
To:_____________
Position Held:______________________________Rate of Pay: __________________
From:___________
Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West
___ Northwest
___ Mountains
Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump
___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____
Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________
Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________
______________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No
Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing?
Yes ___No
________________________________________________________________________________________________
8th to last Employer
Dates of
Employment:
Name:_____________________________ Supervisor:__________________________
Address:__________________________________ Telephone:___________________
City:____________________________State:__________ Zip Code:_______________
To:_____________
Position Held:______________________________Rate of Pay: __________________
From:___________
Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West
___ Northwest
___ Mountains
Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump
___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____
Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________
Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________
______________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No
Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing?
Yes ___No
________________________________________________________________________________________________
9th to last Employer
Dates of
Employment:
Name:_____________________________ Supervisor:__________________________
Address:__________________________________ Telephone:___________________
City:____________________________State:__________ Zip Code:_______________
To:_____________
Position Held:______________________________Rate of Pay: __________________
From:___________
Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West
___ Northwest
___ Mountains
Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump
___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____
Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________
Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________
______________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No
Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing?
Yes ___No
________________________________________________________________________________________________
10th to last Employer
Dates of
Employment:
Name:_____________________________ Supervisor:__________________________
Address:__________________________________ Telephone:___________________
To:_____________
City:____________________________State:__________ Zip Code:_______________
Position Held:______________________________Rate of Pay: __________________
From:___________
Driving Experience: ___ All 48 ___ Midwest ___ South ___ East ___West
___ Northwest
___ Mountains
Equipment Driven: ___ Straight Truck ___Cabover ___Conventional ___Reefer ___Van ___Dump
___Flatbed ___Tanker ___Autohauler ___Doubles Trailer Length:____
Ft. Logbook required:_____ Approximate Total Number of Miles Driven for this Employer:____________
Reason for Leaving: ___Quit ___Fired ___Lay off ___Other ___Explain Circumstances:__________
______________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer? ___Yes ___ No
Was this a safety sensitive function as defined by the DOT subject to alcohol & drug testing?
Yes ___No
Please answer the following questions with a “Yes” or “No”
1. Are you a U.S. Citizen or otherwise lawfully authorized to work in this country? ___Yes ___No
2. Have you ever been convicted of a felony? ___Yes ____No
3. Is there any reason that you might be unable to perform the functions of the job, for which you have
applied, (Truck Driver), i.e.: but not limited to lifting, loading, unloading, minor maintenance, tarping and
securement of loads, fueling, and driving? ___Yes ___No
If yes, explain;__________________________________________________________________________
4. Have you been convicted for driving while intoxicated or driving while under the influence of drugs
within the last five (5) years? ___Yes ___No
5. Are you familiar with the Federal Motor Carrier Safety Regulations? ___Yes ___No
6. Have you ever been denied a bond? ___Yes ___No
7. Have you ever had your driver’s license suspended or revoked? ___Yes ___No
Licensing Information (Must have a valid CDL) List all licenses held the past 5 years
Issuing State
License Number
Type
Expiration
Date
Restrictions
Turned In?
Driving Record
Have you been convicted of any traffic violations in the past 4 years? ___Yes ___No
List all traffic violations except for parking tickets for the last 4 years. If none, write “None”.
Month/Year
Violation
Type of Vehicle
Location, City/State
Penalty/Fine
Points Assessed
Accidents
Have you been involved in any accidents in the past 4 years? ___Yes ___No
List all accidents, preventable, non-preventable, regardless of $$ amount or fault in the past 4
years. If none, write “None.”
Month
/Year
Type of
accident
Type of
Vehicle
Location,
City/State
$$ Amount of
Damages
Number of
Fatalities
Number of
Injuries
Were you
ticketed
Were you
at fault
Cargo Claims
Have you had any cargo claims in the past 4 years? Yes
No
List all claims, preventable, non-preventable, regardless of $$ amount or fault in the past 4 years.
If none, write “None.”
Month/Year
Type of Claim
$$ Amount of Claim
Type of Cargo
Were you
charged for
the claim
Education
Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12
College: 1 2 3 4 5 6 7 8
Check the following that apply: ___High School Diploma ___G.E.D. ___College Degree
___None of these
List any Truck Driving Schools you have attended, dates of completion, and other safety training:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Experience and Qualifications
Driving Positions
Do you have a current DOT Medical Card? ______
Do you have full knowledge of DOT Safety Requirements?_____
Have you ever been disqualified from driving for any of the following:
1. Driving a commercial motor vehicle with a blood alcohol concentration of 0.04 or more? Yes ( ) No ( )
2. Driving under the influence of alcohol, as defined by State law? Yes ( ) No ( )
3. Refusing to submit to an alcohol test at the direction of federal, State or local officials? Yes ( ) No ( )
4. Driving a motor vehicle with a gross vehicle weight rating of 10,001 pounds or more while under the
influence of an illegal drug (including the improper use of prescription drugs)? Yes ( ) No ( )
5. Transporting, possessing or using illegal drugs (including the improper use of prescription drugs) while
on duty? Yes ( ) No ( )
6. Leaving the scene of an accident while operating a commercial motor vehicle? Yes ( ) No ( )
7. Committing a felony involving the use of a motor vehicle with a gross vehicle rating of 10,001 pounds or
more? Yes ( ) No ( )
Have you tested positive in a DOT required drug or alcohol test in the past two years, or refused a test for
an employer who did not hire you? Yes ( ) No ( ) If yes, provide details on a separate sheet of paper.
I hereby acknowledge that prior to submitting this application, I have been informed that the information
provided herein may be used to conduct current and previous employer’s references or any other
individuals this Company considers necessary.
I hereby authorize my current and previous employers, references, and any other individuals contacted by
this company to release any past or present information requested, including but not limited to past drug
and alcohol test results, and I release all providers of said information from any liability stemming from
release of same information.
In connection with my application for employment with this Company, I understand that I have the right to
review, correct or rebut any information obtained from former employers requested by this Company.
I understand that any false, misleading, or incomplete answers or statements shall be considered sufficient
cause for denial or termination of employment and/or authorization to drive.
I understand that nothing contained in this application or in the granting of an interview or a road test is
intended to create an employment contract between this Company and myself, for either employment,
authorization to drive, or for the providing of any benefits. No promises regarding employment or
authorization to drive have been made to me, and no such promises exist unless specifically made by this
Company in writing. If an employment relationship is established, I understand that, as an employee at
will, I have the right to terminate my employment at any time, and this Company has the same right.
______________________________________________________________________________
Print Name
Social Security Number
______________________________________________________________________________
Applicants Signature
Date
Safety Performance History Records Request Part 1
Section 1:
To be completed by prospective Employee
I, (print name) ___________________________________________ Social Security Number:_________________
Hereby authorize:
Date of Birth:_________________________
Previous Employer:__________________________________ Phone #:_________________ Fax:_____________
Address:______________________________________________ City, State, Zip:__________________________
To release and forward the information requested by section 3 of this document concerning my Alcohol and
Controlled Substance Testing records within the previous 3 years from: (applicant date) _______________________
To:
Prospective Employer:________________________________________ Phone #:__________________________
Attention:________________________________________
Address:______________________________________________ City, State, Zip:__________________________
In compliance with §40.25(g) and §391.23(h), release of this information must be made in a written form that ensures confidentiality such as
fax, email or letter.
Prospective employer’s confidential fax number:_____________________________________
Prospective employers confidential email address:____________________________________
Applicants Signature:______________________________________ Date:________________________________
This information is being requested in compliance with §40.25(g) and §391.23(h)
Section 2:
To be completed by Previous Employer
Accident History
(1) The applicant named above was employed by us.
____Yes ____No
Employed as ______________________________ from (M/Y)________________ to (M/Y)_________________
If driver was involved in a safety sensitive position subject to controlled substance and alcohol testing under part 40, check here. []
Did he/she drive motor vehicles for you? ____Yes ____No If yes, what type? __Straight Truck __Tractor-Semi Trailer
__Bus __Tanker __Doubles/Triples __Other (specify):_________________________________________________________
(2) Reason for leaving your employment: ____Discharged ____Resignation ____Lay off ____Military Duty
If there is no safety performance history to report, check here []
sign below and return.
Accidents: Complete the following for any accidents included on your accident register (390.15(b)) that involved the applicant
in the 3 years prior to the application date shown above or check here [] if there is no accident register data for this applicant.
Date
Location
# of Injuries
# of Fatalities
Hazmat Involved
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Please provide information concerning any other accidents involving the applicant that were reported to government agencies or
insurers or retained under internal company policies: ____________________________________________________________
_______________________________________________________________________________________________________
Any other remarks:_______________________________________________________________________________________
_______________________________________________________________________________________________________
SAFETY PERFORMANCE HISTORY RECORDS REQUEST Part 2
Signature:_____________________________________ Title:_________________________ Date:_____________________
Safety Performance History Records Request Part 2
Section 3:
To be completed by Previous Employer
If the driver was not subjected to DOT testing requirements while employed by this employer, please check here [], fill in the dates of
employment from ______________ to_____________, complete bottom of section 3, sign and return.
Driver was subject to DOT testing requirements from_______________________ to________________________.
1. Has this person had an alcohol test with a result of 0.04 or higher alcohol concentrations?
____Yes ____No
2. Has this person tested positive or adulterated or substituted a test specimen for controlled substances?
____Yes ____No
3. Has this person refused to submit to post-accident, random, reasonable suspicion or follow-up alcohol
controlled substance test?
____Yes ____No
4. Has this person committed other violations of subpart B or Part 382 or part 40?
____Yes ____No
5. If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP
prescribed rehabilitation program in your employ, including return-to-work and follow-up tests? If yes, please send documentation
back with this form.
____Yes ____No
6. For a driver who successfully completed a SAP’s rehabilitation referral and remained in you r employment, did this driver
subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test or refuse to be tested?
____Yes ____No
In answering these questions, include any required DOT drug and alcohol testing information obtained from previous employers in the
previous 3 years prior to the application date on Part 1.
Name:_________________________________________________________________________________________________
Company:______________________________________________________________________________________________
Address:______________________________________________________ City, State, Zip:____________________________
Section 3 Completed by (signature):___________________________________________________ Date:_____________________________
Section 4:
This form was (checked one):
To be completed by Prospective Employer
____Faxed to Previous Employer
____Mailed
____Emailed
____Other:_____________________
By:______________________________________________________________________________ Date:__________________________
Section 4a:
To be completed by Prospective Employer
Complete below when information is obtained.
Information obtained from:_________________________________________________________________________________
Recorded by:____________________________________________ Method: ____Fax ____Mail ____Email ____Telephone
Date:___________________________________________________ Other__________________________________________
Instructions: Complete the Safety Performance History Records Request
Part 1 Section 1: Prospective employee
Complete the information required in this section
Sign and Date
Submit to Prospective Employer
Part 2 Sections 4: Prospective Employer
Complete the information
Send to Previous Employer
Part 1 Section 2: Previous Employer
Complete the information requested in this section
Sign and Date
Part 2 Sections 3: Previous Employer
Complete the information required in this section
Sign and Date
Return to Prospective Employer
Part 2 Section 4a: Prospective Employer
Record receipt of information
Retain the form
DRIVER/APPLICANT SAFETY PERFORMANCE HISTORY RECORDS REQUEST
This request is made by the driver/applicant in compliance with DOT regulation; 391.23 Investigations and inquiries, paragraphs (I)(1) & (2)
Section 1
To:
Completed by the Driver/Applicant
Prospective Employer:
________________________________________________________________
Address:
________________________________________________________________
City, State, Zip Code: _________________________________________________________________
From:
Driver/Applicant:
___________________________Social Security/ID #:____________________
Address:
_______________________________________________________________
City, State, Zip Code:
__________________________________Phone Number_________________
I am submitting this written request for copies of my Department of Transportation Safety Performance History for the preceding
three (3) years. I understand for records requested from a prospective employer, that I must arrange to pick up or receive the
requested records within thirty (30) days of the records being made available or I have waived my request to review the records.
This information should be: ____Mailed to me at the above address
other party)
____I will pick up (Will not be given to any
Driver/Applicant:_________________________________________________
Date:______/______/_______
Signature
Section 2:
month
day
year
Completed by the Prospective Employer
The information must be provided to the applicant within five (5) business days of receiving the written request. IF
the prospective employer has not yet received the requested information from the previous employer(s), then the five
business days deadline will begin when the prospective employer receives the requested safety performance history
information.
Information Supplied to:
Name:___________________________________________
Comments:__________________________________
Address:_________________________________________
__________________________________________
City, State, Zip Code:_______________________________
__________________________________________
By:
_____________________________________________________
Signature of person providing the information
________________________
Telephone Number
Release Date:_____/______/______
MM
DD
YY
Applicant Must Read, Initial, Sign and Date
This certifies that I completed this application, and that all entries on it and information in it are true and
complete. I hereby certify that I have read and fully understand this application. Prior to signing below, I
had the opportunity to ask Norsemen Trucking, Inc. about, and clarify any questions I might have had
concerning this application form. ________________(Initial)
I affirm that I have a genuine intent and no other purpose in applying for a job with this company. I hereby
certify that the answers given by me on this application form are all true and correct. I understand and
agree that any misrepresentations or intentional omissions made by me on this application, on other
documents used by Norsemen Trucking, Inc. in support of this application, and/or made during any
interviews conducted in conjunction with my application for a position, will be sufficient reason to render
me ineligible or result in my subsequent termination by Norsemen Trucking, Inc. at any time, and I
understand and agree that the denial of position or my termination for such grounds shall be without
liability to Norsemen Trucking, Inc. I also understand that if hired, I will be on a six (6) month probation
and may be disqualified and subsequently terminated without recourse. ________________ (Initial)
I authorize Norsemen Trucking, Inc. to make such investigations and inquiries of my personal references,
past employment, driving record (when job related), education, criminal record, including character and
general reputation and/or other job related matters as may be necessary in arriving at an employment
decision. I hereby release employers, supervisors, educational institutions, or other persons from all
liability in responding to inquiries in connection with my application. I authorize a copy or facsimile of
this form to be as valid as the original. _________________(Initial)
I understand Norsemen Trucking, Inc. does not enter into employment contracts with employees, and that
this application does not constitute a job offer, either expressed or implied. Norsemen Trucking, Inc. does
not guarantee a position, and that an employment contract is not created in the event I may be eventually
offered a position. Further, I understand and agree that no representative of Norsemen Trucking, Inc. has
the authority to enter into any agreement, either expressed or implied, or commit to the utilization of my
services for any specified period of time. _________________(Initial)
I understand and agree that this application is limited to the specific position for which I am applying, and
that it will remain in an active status for a period ninety (90) days from that application date, and that if I
am not offered the position for which I am applying within the ninety (90) day period of this application, I
will not be considered for other positions or openings. I understand that I may reapply with Norsemen
Trucking, Inc. under the same conditions, by completing and submitting a new application.
____________________(Initial)
I understand also, that I will be expected to, and agree to abide by all work and safety rules of the Company
as required or permitted by law. I understand and agree that my failure to abide by any rule will be
sufficient reason for my termination by Norsemen Trucking, Inc. at any time, and I understand and agree
that my termination for such ground shall be without liability to Norsemen Trucking, Inc.
_______________(Initial)
I understand and fully agree that this application is limited to the specific position for which I am applying.
I understand and agree that in order to be offered a position, I must be able to perform the essential
functions of the job (without, or with reasonable accommodation as may be required).
____________(Initial)
______________________________________________________________________________________
Applicant Signature
Date