PRE-EMPLOYMENT SCREENING

This online application is part of A & M Transport, Inc.'s screening process for considering applicants for employment with the company. In order to apply, applicant must be in possession of a valid CDL (Commercial Drivers License) and a current Medical Examiner's Certificate. If selected for employment, applicant will be required to appear at the home office in Glendale Oregon during regular business hours to formally complete the application process. In addition, if selected, employment will be contingent upon verification of the information submitted, verification of employment eligibility, background and past employment checks, successful driving test, submitting to and passing a D.O.T. physical and drug test and meeting various other Company requirements.

Please check the box if you have read, understand, and agree with the above statement.


PERSONAL INFORMATION

First Name: Middle Initial: Last Name:

Addresses you have resided in the last three (3) years.

Address: City: State: Zip: How Long:

Address: City: State: Zip: How Long:

Address: City: State: Zip: How Long:

Address: City: State: Zip: How Long:

Phone Number: 123-456-7890

Birthdate: MM/DD/YYYY

Social Security Number: 123-45-6789

Email Address:


EMPLOYMENT INFORMATION

Who referred you?:

Are you 21 years of age or over?:

Have you previously been employed by A&M Transport, Inc?:
Below list the dates of employment at A & M Transport, Inc., the position in which you worked and the reason for leaving.

Are you employed at the present time?:

Employer's Name:

Employer's Address:

Have you ever been convicted of a felony?:
If YES, please explain fully in the box blow. Conviction of a crime will not necessarily disqualify you from consideration for employment.


EDUCATION

Last School Attended:

City & State:


EXPERIENCE & QUALIFICATIONS

Do you have a CDL? (Commercial Drivers License) :

List unexpired commercial motor vehicle operator's licenses currently held. 49 CFR 391.21(b)(5)

License #: Issuing State: Expiration Date: MM/DD/YYYY

Do you have a current medical card?: Expiration Date: MM/DD/YYYY

Total years of truck driving experience:
If you have driven for less than one year, please indicate below what accredited truck driving school you attended and the year you graduated.

Truck Driving School:

City & State:

Year Graduated:

Provide your experience in the operation of motor vehicles, including the type of equipment (buses, trucks, truck tractors, semitrailers, full trailers, and pole trailers) which you have operated. 49 CFR 391.21(b)(6)

53ft Vans Experience: Number of years:

Flatbed Experience: Number of years:

Tautliner Experience: Number of years:

Other Experience:
In the box below, please list any other truck driving experience you have.

Have you ever been denied a license, permit or privilege to operate a motor vehicle?:
Is YES, in the box below, please explain the reason for the denial. 49 CFR 391.21(b)(9)

For the last 3 years please list all motor vehicle accidents in which you were involved during the 3 years preceding the date the Driver Qualification form was submitted, specifying the date and nature of each accident and any fatalities or Personal injuries it caused. 49 CFR 391.21(b)(7)

Date: MM/DD/YYYY Nature of Accident: # of Fatalities: # of Injuries:

Date: MM/DD/YYYY Nature of Accident: # of Fatalities: # of Injuries:

Date: MM/DD/YYYY Nature of Accident: # of Fatalities: # of Injuries:

Date: MM/DD/YYYY Nature of Accident: # of Fatalities: # of Injuries:

For the last 3 years list all violations of motor vehicle laws or ordinances (other than violations involving only parking) of which you were convicted or forfeited bond or collateral during the 3 years preceding the date the Driver Qualification From was submitted. 49 CFR 391.21(b)(8)

Date: MM/DD/YYYY Location (City): State: Charge/Violation:

Date: MM/DD/YYYY Location (City): State: Charge/Violation:

Date: MM/DD/YYYY Location (City): State: Charge/Violation:

Date: MM/DD/YYYY Location (City): State: Charge/Violation:


EMPLOYMENT EXPERIENCE

Begin with your present experience and work backward in order, listing all employers, military, self-employment, driving school, and other training programs for at least ten (10) years. Leave NO gaps in time for past 10 years. All time must be accounted for. We must have complete addresses and telephone numbers.

Present Employer

Company Name:

Supervisor's Name:

Address:

City:

State:

Zip:

Phone Number: 123-456-7890

Position Held:

From: MM/DD/YYYY To: MM/DD/YYYY

Was this position subject to the FMCSR? YES NO

Was this position a safety sensitive function subject to alcohol and controlled substance testing requirements of 49CFR PART 40? YES NO

Reason for Leaving

Previous Employer

Company Name:

Supervisor's Name:

Address:

City:

State:

Zip:

Phone Number: (123)456-7890

Position Held:

From: MM/DD/YYYY To: MM/DD/YYYY

Was this position subject to the FMCSR? YES NO

Was this position a safety sensitive function subject to alcohol and controlled substance testing requirements of 49CFR PART 40? YES NO

Reason for Leaving

Previous Employer

Company Name:

Supervisor's Name:

Address:

City:

State:

Zip:

Phone Number: (123)456-7890

Position Held:

From: MM/DD/YYYY To: MM/DD/YYYY

Was this position subject to the FMCSR? YES NO

Was this position a safety sensitive function subject to alcohol and controlled substance testing requirements of 49CFR PART 40? YES NO

Reason for Leaving

Previous Employer

Company Name:

Supervisor's Name:

Address:

City:

State:

Zip:

Phone Number: (123)456-7890

Position Held:

From: MM/DD/YYYY To: MM/DD/YYYY

Was this position subject to the FMCSR? YES NO

Was this position a safety sensitive function subject to alcohol and controlled substance testing requirements of 49CFR PART 40? YES NO

Reason for Leaving

Previous Employer

Company Name:

Supervisor's Name:

Address:

City:

State:

Zip:

Phone Number: (123)456-7890

Position Held:

From: MM/DD/YYYY To: MM/DD/YYYY

Was this position subject to the FMCSR? YES NO

Was this position a safety sensitive function subject to alcohol and controlled substance testing requirements of 49CFR PART 40? YES NO

Reason for Leaving


Authorization

IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with A & M TRANSPORT, INC. ("Prospective Employer"), it may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). If the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any otheradverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize A & M TRANSPORT, INC. ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

Electronic Signature: (Please type your name in the box to be used as your electronic signature)


Authorization

REQUEST FOR CHECK OF DRIVING RECORD

AS REQUIRED BY U.S. DEPARTMENT OF TRANSPORTATION MOTOR CARRIERS SAFETY PROGRAM PURSUANT TO 49 CFR 391.23

The above listed individual has made application with us for employment as a driver. Applicant has indicated that the above numbered operator's license or permit has been issued by your State to applicant and that it is in good standing.

In accordance with Section 391.23(a) (1) and (b) of the Federal Motor Carrier Safety Regulations, we are required to make inquiry into the driving record during the preceding three years of every State in which an applicant-driver has held a motor vehicle operator's license or permit during those three years.

Therefore, please certify to us what the individual's driving record is for the preceding three years, or certify that no record exists if that be the case.

In the event that this inquiry does not satisfy your requirements for making such inquiries, please send us such forms as are necessary for us to complete our inquiry into the driving record of this individual.

I hereby authorize the release my driving record to A & M Transport, Inc. for the purposes 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.

Electronic Signature: (Please type your name in the box to be used as your electronic signature)


Acknowledgement

By electronically signing and submitting this application, you agree as follows:

I understand and acknowledge that the information contained in this application will be used for employment screening purposes. I hereby authorize A & M Transport, Inc. and its employees, agents, representatives and contractors to conduct an investigation of my background for employment purposes. The background investigation may include, but is not limited to, information pertaining to my character, past work experience, educational background, criminal history, driving record, safety performance history, crash and inspection history, alcohol and controlled substance test results (or my failure to submit to an alcohol or controlled substance test), and any other information about me that may reflect upon my potential for employment. I understand that my background information may be obtained from any individual or entity, including, but not limited to, previous employers in accordance with applicable law. I agree that I will hold A & M Transport, Inc. and its employees, officers, shareholders, agents, representatives and contractors harmless from any and all claims, loss and/or liability which may result from information provided or obtained in the background investigation.

I understand and acknowledge that any false statement, omission, or misrepresentation on or in this application, or on or in any document that I provide or cause to be provided to A & M Transport, Inc. in consideration of employment, shall be grounds for rejection of this application or immediate discharge if I am employed, regardless of the time elapsed before discovery.

I understand and agree that nothing contained in this application is intended to create an employment contract.

I understand that I have the following rights regarding information provided by my previous employers:

  • The right to review information provided by previous employers;
  • The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer; and
  • The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
  • By submitting this application, I certify that this application was personally completed by me and that all of the information submitted is true and complete to the best of my knowledge. I further certify that the signature below is my electronic signature and acknowledge its validity.

    I acknowledge that I have read and accept the terms of this employment application.

    Electronic Signature: (Please type your name in the box to be used as your electronic signature)

    Please type the two words in the box below and then hit submit.