Space City Hot Shot Driver Application


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.

Applicant Name:(Please Print)
Date:
TO BE READ AND SIGNED BY APPLICANT

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 to 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 event of employment, I understand that false or misleading information given in my application of interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company.
I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23 (d) and (e). I understand that I have the right to:

  • Review information provided by the previous employers
  • Have errors in the information corrected by the previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
  • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
Signature:

Date:

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.

Date of application

PLEASE SELECT ONE OF THE FOLLOWING:

PLEASE SELECT ONE OF THE FOLLOWING:
Name
Last *  
First *  
Middle
S.S.# *  
Address
Street *  
City *  
State *  
Zip *  
Phone *  
Address for Past Three Years
Street
City
State
Zip
How Long?
Street
City
State
Zip
How Long?
Do You Have Legal Right To Work In The United States?
Date of Birth (Required for Truck Drivers)
Can You Provide Proof of Age?
Have You Worked For This Company Before?
Where?
Dates:
From
To
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?
If yes, please explain.
EMPLOYER
Name
Address
City
Contact Person
Phone Number
DATE
From
To
Position Held
Salary/Wage
Reason for Leaving
Were you subject to the FMCSR’s while employed?
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49CFR Part 40?

EMPLOYER
Name
Address
City
Contact Person
Phone Number
DATE
From
To
Position Held
Salary/Wage
Reason for Leaving
Were you subject to the FMCSR’s while employed?
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49CFR Part 40?

EMPLOYER
Name
Address
City
Contact Person
Phone Number
DATE
From
To
Position Held
Salary/Wage
Reason for Leaving
Were you subject to the FMCSR’s while employed?
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49CFR Part 40?

EMPLOYER
Name
Address
City
Contact Person
Phone Number
DATE
From
To
Position Held
Salary/Wage
Reason for Leaving
Were you subject to the FMCSR’s while employed?
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49CFR Part 40?

EMPLOYER
Name
Address
City
Contact Person
Phone Number
DATE
From
To
Position Held
Salary/Wage
Reason for Leaving

Includes vehicles having a GVWR of 26,001 pounds or more, vehicles designed, to transport 15 or more passengers, or any size vehicles used to transport hazardous materials in a quantity requiring placards.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or sued to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in the quantity requiring placards.

Accident Record for Past 3 Years or More (Attach Sheet if More Space is needed)
DATESNATURE OF ACCIDENTFATALITIESINJURIES
Last Accident
Next Previous
Next Previous

List all accidents that you have been involved in that resulted in vehicles being towed, individuals transported from the scene via ambulance seeking medical treatment, or if a fatality was involved. (10 Years or More - Attach Sheet if More Space is Needed)

DATESNATURE OF ACCIDENTFATALITIESINJURIES
Last Accident
Next Previous
Next Previous

Traffic Convictions and Forfeitures for the past 3 years (Other than parking violations)
LOCATIONDATECHARGEPENALTY

EDUCATION

Select Highest Grade Completed:
High School:
College :
Last School Attended
City

EXPERIENCE AND QUALIFICATIONS – DRIVER

CLASS OF EQUIPMENTTYPE OF EQUIPMENT FROMTO APPROX. NO. OF MILES
List states operated in for last 5 years:

Show special courses or training that will help you as a driver:
Which safe-driving awards do you hold and from whom?
DRIVERS LICENSESSTATE LICENSE NUMBERTYPE 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 been suspended or revoked?
Explain circumstances and outcome of conviction:
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

I certify 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 Freeway Delivery, Inc. to make such investigations and inquiries of my personal, employment, financial, medical, criminal histories and other related matters. I have the full understanding that Freeway Delivery, Inc. reserves the right to arrive at a decision based on any information obtained from such inquiries and investigations. 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. I understand that false or misleading information given in my application or interview(s) may result in termination of contract. I understand that I am required to abide by all rules and regulations of the Company.

Signature:

Date:

I, , certify that I have never been arrested, convicted, accused, or charged with any type of DWI (Driving While Intoxicated), DUI (Driving under the Influence), or PI (Public Intoxication).
I understand that the company has a zero-tolerance policy as far as drugs and alcohol are concerned. I also understand if I falsified my application or this form and the company discovers any un-truths, my application will be disqualified or my lease will be terminated.

Applicant:

Date:
FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, (Public Law 91-508), as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that a consumer report may be obtained on you for employment purposes.
I acknowledge the receipt of the above disclosure and authorize the above-named company to obtain a consumer report on me for employment purposes. This authorization is ongoing in the event such a report is needed in the future.


Applicant’s Signature

Print Name
Social Security Number
Date