Download - M. Gerace Inc.

434 PRIMOS AVENUE FOLCROFT, PA 19032
DRIVER APPLICATION (yes or no)
INDEPENDENT CONTRACTOR (yes or no)
Recruiting call 888-890-0899 or 484-494-5777 Fax 610-534-2500
PERSONAL INFORMATION
Name:
Date:
Home Phone:
Cell Phone:
Present Address (street, city, state, zip):
How long have you lived at this address?
Prior Address: (street, city, state, zip):
How long did you lived at this address?(if at present address less than 5 years)
Social Security Number:
Date of Birth:
E-Mail Address:
Have you ever been known by another name ( Maiden, nickname, etc..)?
If yes, list name:
How did you hear about us?
EDUCATION AND TRAINING
Highest year of school completed:
Do you have: High School Diploma YES / No or G.E.D.
List any training program presently attending or completed (truck driving schools,
service schools etc..)
School Name City State
Phone
Did you Graduate Yes / No
TRACTOR INFORMATION ( INDEPENDENT CONTRACTORS)
Tractor Make
Year
Empty Weight
Wheelbase
Fifth Wheel Height
Name listed on title
Lien Holder
Lien Holder Address
Street
City State
Monthly Note Amount $
Zip
Personal History for Past 10 Years Begin with your present experience and work
backwards in order, listing all of your employers, driving schools and other
training programs, periods of unemployment and self-employment for at least 10
years All time must be accounted for. Use additional sheets if necessary. Fill in
all information.
Dates: (from Month/Year to Month/Year)
Position Held
Company
Avg Weekly Earnings
Reason for Leaving
Address
City
State
Zip
Tele. #
Supervisors Name
Number of Accidents
Type Equipment Pulled
Type Equipment Driven
Total Miles Driven
Full or Part Time
Hours or Miles Week
Was this job a safety sensitive function as defined by DOT and subject to Drug/Alcohol testing?
Dates: (from Month/Year to Month/Year)
Position Held
Company
Avg Weekly Earnings
Reason for Leaving
Address
City
State
Zip
Tele. #
Supervisors Name
Number of Accidents
Type Equipment Pulled
Type Equipment Driven
Total Miles Driven
Full or Part Time
Hours or Miles Week
Was this job a safety sensitive function as defined by DOT and subject to Drug/Alcohol testing?
Dates: (from Month/Year to Month/Year)
Position Held
Company
Avg Weekly Earnings
Reason for Leaving
Address
City
State
Zip
Tele. #
Supervisors Name
Number of Accidents
Type Equipment Pulled
Type Equipment Driven
Total Miles Driven
Full or Part Time
Hours or Miles Week
Was this job a safety sensitive function as defined by DOT and subject to Drug/Alcohol testing?
Dates: (from Month/Year to Month/Year)
Position Held
Company
Avg Weekly Earnings
Reason for Leaving
Address
City
State
Zip
Tele. #
Supervisors Name
Number of Accidents
Type Equipment Pulled
Type Equipment Driven
Total Miles Driven
Full or Part Time
Hours or Miles Week
Was this job a safety sensitive function as defined by DOT and subject to Drug/Alcohol testing?
Print Name Work History Continuation (if necessary to complete 10 years)
Dates: (from Month/Year to Month/Year)
Position Held
Company
Avg Weekly Earnings
Reason for Leaving
Address
City
State
Zip
Tele. #
Supervisors Name
Number of Accidents
Type Equipment Pulled
Type Equipment Driven
Total Miles Driven
Full or Part Time
Hours or Miles Week
Was this job a safety sensitive function as defined by DOT and subject to Drug/Alcohol testing?
Dates: (from Month/Year to Month/Year)
Position Held
Company
Avg Weekly Earnings
Reason for Leaving
Address
City
State
Zip
Tele. #
Supervisors Name
Number of Accidents
Type Equipment Pulled
Type Equipment Driven
Total Miles Driven
Full or Part Time
Hours or Miles Week
Was this job a safety sensitive function as defined by DOT and subject to Drug/Alcohol testing?
Dates: (from Month/Year to Month/Year)
Position Held
Company
Avg Weekly Earnings
Reason for Leaving
Address
City
State
Zip
Tele. #
Supervisors Name
Number of Accidents
Type Equipment Pulled
Type Equipment Driven
Total Miles Driven
Full or Part Time
Hours or Miles Week
Was this job a safety sensitive function as defined by DOT and subject to Drug/Alcohol testing?
Dates: (from Month/Year to Month/Year)
Position Held
Company
Avg Weekly Earnings
Reason for Leaving
Address
City
State
Zip
Tele. #
Supervisors Name
Number of Accidents
Type Equipment Pulled
Type Equipment Driven
Total Miles Driven
Full or Part Time
Hours or Miles Week
Was this job a safety sensitive function as defined by DOT and subject to Drug/Alcohol testing?
List ALL drivers licenses held in the past 5 years
(include multiple licenses if you have them):
Motor Vehicle Record Qualifications:
State
License Number
CDL Class
Endorsements
Exp. Date
Accident Record (if no accidents write none)
List ALL accident involvements with ANY motor vehicle for the past 5 years (even
if not at fault)
Date
Type of
Vehicle
Nature of
Accident
Where
you at
fault?
Where you
ticketed?
Number of
Fatalities
Number
of
Injuries
Amount
of
Damage
Points
Assigned
Traffic Convictions (if none, write none)
Date
Location (citystate)
Violation (if
speeding how fast)
Fine or Penalty
Points Assigned
Have you ever been convicted of or plead guilty or nolo contender (no contest) to
a crime, other than a traffic violation?
Have you ever been denied a license, permit or privilege to operate a motor
vehicle?
Has any license, permit or privilege ever been suspended or revoked?
Have you ever been refused any type of insurance or been denied bonding?
If you answered YES to any of the above, please explain
CONDITIONS FOR CONTRACTING
I certify that I have personally completed this application using information that is true and correct
to the best of my knowledge and belief. I fully understand that any false statement or omission of
any fact on this application or any other material submitted to M. GERACE ENTERPRISES INC.
may be considered sufficient cause for rejection or disqualification.
I hereby grant M. GERACE ENTERPRISES INC. permission to verify this information and I agree
to furnish any additional information requested by M. GERACE ENTERPRISES INC.. I
understand M. GERACE ENTERPRISES INC. or its agents may investigate my background to
ascertain any information any information related to my work record, work experience, credit
information, education, or training. This background check may use the consumer reports
containing past employment history obtained from a third party. I consent to M. GERACE
ENTERPRISES INC. making the request for any such consumer reports and hold harmless and
indemnify M. GERACE ENTERPRISES INC from all liability, claims, or damages resulting from
obtaining verification information. It is agreed and understood that this application is in no way
imposes an obligation upon M. GERACE ENTERPRISES INC I understand that M. GERACE
ENTERPRISES INC is under no obligation to me or my agents to furnish any investigative
findings regarding my previous work experience/performance, or education/training.
I agree to submit to all applicable test examinations, and inquiries as may be required by M.
GERACE ENTERPRISES INC. such as medical examinations, drug screen testing, and agility
testing (if applicable) in accordance with Federal Department of Transportation requirements and
M. GERACE ENTERPRISES INC. policies and procedures.
If I am qualified and become a qualified employee or leased equipment driver for M. GERACE
ENTERPRISES INC I agree to submit to any drug and/or alcohol test as required by M. GERACE
ENTERPRISES INC. policy or Federal Department of Transportation Regulations. I agree to hold
harmless and indemnify M. GERACE ENTERPRISES INC., its officers, directors, employees,
independent contractors, and any designated medical group and its agents, servants, or
employees from any loss, damage, expense, or any other injury arising out of the drug and/or
alcohol testing. I understand that refusing to submit to such testing at any time when requested
by M. GERACE ENTERPRISES INC. will constitute grounds for disqualification. I authorize
M. GERACE ENTERPRISES INC. to release information about positive drug and/or alcohol test
results to any local, state, or federal government agency or public or private company or
corporation.
I authorize M. GERACE ENTERPRISES INC to obtain from the appropriate state, local, or federal
authorities copies of my Motor Vehicle Report or similar reports as part of my qualification file.
I hereby acknowledge that this document is not a contract or offer of employment. I understand
that I will not become an M. GERACE ENTERPRISES INC. qualified leased equipment driver or
employee until I have met all conditions of qualification and completed all paperwork related to
qualification.
I understand that M. GERACE ENTERPRISES INC. is under no obligation to contract with me. I
understand if offered a contract or employment I may be disqualified by M. GERACE
ENTERPRISES INC. at any time, with or without cause.
I further understand that if contracted/leased to M. GERACE ENTERPRISES INC. I will not be an
employee of M. GERACE ENTERPRISES INC. but will be an independent contractor leased to
M. GERACE ENTERPRISES INC, or I, will be an employee of an independent contractor with
equipment leased to M. GERACE ENTERPRISES INC.. I fully understand my contract will be
governed by law and applicable M. GERACE ENTERPRISES INC. policies and procedures.
If qualified I understand that I will be subject to Federal Department of Transportation Regulations
applicable to professional drivers and I understand that I must comply with these regulations.
X APPLICANTS SIGNATURE
DATE
PRINTED NAME
EMERGENCY NOTIFICATION
In case of emergency, notify
NAME
PHONE
RELATIONSHIP
ADDRESS
CITY / STATE
REFERENCES
Name:
Phone
Years Known
ADDRESS
CITY
STATE
PLACE OF EMPLOYMENT
OCCUPATION
Name:
Phone
Years Known
ADDRESS
CITY
STATE
PLACE OF EMPLOYMENT
OCCUPATION
APPLICANT: PLEASE SIGN AT THE X AT THE BOTTOM / DO NOT
COMPLETE FORM
Date
Social Security #
To Former employer:
Has completed an application to M. GERACE INC. for the position of tractor trailer driver, and
states that he/she was Employed by you from to. Will you kindly reply to the inquiry below
regarding this applicant. Your reply will be held in strict confidence and will in no way involve you
in any responsibility.
Is employment record with your company correct as listed above?
What kind of work did the applicant do?
Did the applicant have custody of money or valuables?
Were the accounts properly maintained ?
If employed as a driver, please specify type of equipment driven.
Number of accidents
Number of preventable accidents
Dates and nature of accidents
Was applicants’ drivers’ license ever suspended or revoked?
Reason for leaving your employ.
Is applicant competent for the position he/she is seeking?
Would you re-employ
Remarks
By: (SIGNATURE OF PERSON COMPLETING THIS FORM)
By signing below I authorize the above named employer to release to M.
GERACE INC. any and all information concerning my employment; in
compliance with 49CFR 391.23. I also agree that any information obtained by
this inquiry becomes the sole and exclusive property of M. GERACE INC.
X Drivers Signature
Date
VERIFICATION OF CONTROLLED SUBSTANCE / ALCOHOL TESTING
COMPLIANCE PURSUANT TO 49 CFR & PART 382 FMCSR
APPLICANT : PLEASE SIGN AT BOTH X's BELOW - DO NOT COMPLETE
THE FORM
NAME OF APPLICANT:
SOCIAL SECURITY NUMBER
The above named individual as applied for employment as a driver with M.GERACE INC.
1
Has this person tested positive for a controlled substance within the previous three (3)
years YES NO
2
Has this person tested .04 or higher for breath alcohol YES NO within the previous
three (3) years
3
has this person refused to comply with a legal request for a controlled substance breath
alcohol within the previous three (3) years YES NO
4
Has this person violated and other areas of D.O.T. drug and alcohol testing regulations
within the previous three (3) years
YES NO
5
Have you received from any previous employer information that the individual violated
D.O.T. drug and alcohol regulations (40.25c)
YES NO
6
If you answered YES to any of these questions please explain the circumstances
surrounding your answer
Person providing this information:
NAME:
COMPANY
PHONE
I hereby authorize the release of the information requested above concerning my
employment
X Drivers Signature
Date
I certify, in accordance with 49 CFR 40.25, that I have not tested positive, or
refuses to test, on any pre-employment drug or alcohol test administered by an
employer to which I have applied, but was not hired, to perform safety-sensitive
transportation work covered by D.O.T. agency drug and alcohol testing rules
during the past three (3) years.
X Drivers Signature
Date
Information Requested for:
Name:
CDL/License #
Issuing State:
Expiration Date:
Date of Birth:
FAIR CREDIT REPORTIING ACT (FCRA) DISCLOSURE AND
AUTHORIZATION
In accordance with the provisions of section 604(b) (2) (A) of the Fair Credit Reporting Act
(FCRA) (TITLE II, Subtitle D Chapter 1 Public Law 104-208) you are hereby informed that a
consumer report about you may be ordered and used for employment purposes and to determine
insurance eligibility. (Under the provisions of the Act, a driving record, credit report, and insurance
scoring report are all considered a consumer report when used for employment purposes)
I the undersigned acknowledge receipt of the above disclosure and authorize the above named
company(ies) to obtain a consumer report about me for its use related to employment purposes
and in determining insurance eligibility. I the undersigned also acknowledge that M. Gerace
Enterprises Inc. is authorized to request a Motor Vehicle Report (MVR) report about me and that
they are authorized to release the MVR report to the company referenced above that I am either
already employed by or requesting employment of. I the undersigned agree to hold harmless M.
Gerace Enterprises Inc. from any and all liability in connection with their acquisition,
interpretation, use of, or recommendation regarding the information contained in my Motor
Vehicle Report (MVR)
X Signature
Date
Printed Name