APPLICATION FOR PLACEMENT

TO BE READ AND SIGNED BY APPLICANT

It is agreed and understood that any misrepresentations of information given to the above shall be considered an act of dishonesty.

It is agreed and understood that the employer 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 and damages on account of his / her furnishing such information.

The applicant agrees to furnish such additional information and complete such examinations as may be required to complete his / her employment file.

It is agreed and understood that if hired, the employee may be on a probationary period during which time he / she may be discharged 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.

I understand that the information in this application will be used and prior employers will be contacted for purposes of investigation as required by 391.23 of the Motor Carrier Safety Regulations.

Name, First  Middle  Last  Phone Number  Social Security Number 
Address, street  City  State  Zip  How Long? 
months
ADDRESS FOR PAST THREE YEARS
Address, streetCityStateZipHow Long?
months
Address, streetCityStateZipHow Long?
months
Sex  Height  Weight  Date of Birth  Marital Status  No. of Dependants Age of Dependants
Is your spouse working?  If Yes, Where? Do you Own Home or Rent?  Avg Monthly Living Expenses 
In Case of Emergency Notify:
Name 
Address 
Phone 
               
EXPERIENCE AND QUALIFICATIONS - DRIVER
 Driver Licenses:
State  License Number  Type  Expiration Date 
StateLicense NumberTypeExpiration Date
StateLicense NumberTypeExpiration 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. Have you ever been convicted of a felony? 
D. Have you ever tested positive or refused a drug or alcohol test? 
IF THE ANSWER TO EITHER A, B, C OR D IS YES, PLEASE PROVIDE FULL DETAILS
Show Special Courses or Training that will help you as a driver:
Which safe driving awards do you hold and from whom?
ACCIDENT RECORD FOR THE PAST THREE YEARS
 
Date		Nature of Accident
(Head-On, Rear-end, upset, etc.)
Fatalities
Injuries
Last Accident
Next Previous
Next Previous
Next Previous
10 YEAR EMPLOYMENT RECORD
Last Employer's Name  Phone 
Address, street  City  State  Zip 
Position Held
(if Driver, Complete Next Two Boxes) 
Type Trailer
Commodities Hauled		 Dates:
From 
To 
Reasons for Leaving 

Second Last Employer's NamePhone
Address, streetCityStateZip
Position Held
(if Driver, Complete Next Two Boxes)
Type Trailer
Commodities Hauled		Dates:
From
To
Reasons for Leaving

Third Last Employer's NamePhone
Address, streetCityStateZip
Position Held
(if Driver, Complete Next Two Boxes)
Type Trailer
Commodities Hauled		Dates:
From
To
Reasons for Leaving

Fourth Last Employer's NamePhone
Address, streetCityStateZip
Position Held
(if Driver, Complete Next Two Boxes)
Type Trailer
Commodities Hauled		Dates:
From
To
Reasons for Leaving

Fifth Last Employer's NamePhone
Address, streetCityStateZip
Position Held
(if Driver, Complete Next Two Boxes)
Type Trailer
Commodities Hauled		Dates:
From
To
Reasons for Leaving

Sixth Last Employer's NamePhone
Address, streetCityStateZip
Position Held
(if Driver, Complete Next Two Boxes)
Type Trailer
Commodities Hauled		Dates:
From
To
Reasons for Leaving

Seventh Last Employer's NamePhone
Address, streetCityStateZip
Position Held
(if Driver, Complete Next Two Boxes)
Type Trailer
Commodities Hauled		Dates:
From
To
Reasons for Leaving

Eighth Last Employer's NamePhone
Address, streetCityStateZip
Position Held
(if Driver, Complete Next Two Boxes)
Type Trailer
Commodities Hauled		Dates:
From
To
Reasons for Leaving

Ninth Last Employer's NamePhone
Address, streetCityStateZip
Position Held
(if Driver, Complete Next Two Boxes)
Type Trailer
Commodities Hauled		Dates:
From
To
Reasons for Leaving

Tenth Last Employer's NamePhone
Address, streetCityStateZip
Position Held
(if Driver, Complete Next Two Boxes)
Type Trailer
Commodities Hauled		Dates:
From
To
Reasons for Leaving

DISCLOSURE AND RELEASE REGARDING BACKGROUND REPORTS

In connection with my application for employment (including contract for services) with Meteor Express, I understand that consumer reports, that contain public record information, will be requested. Safety performance information including crash data from previous five years and DOT inspections history from the PSP online service for the previous three years will also be requested. Among these reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, drug and alcohol information, etc., I further understand that such reports may contain public record information concerning my driving record, workers compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information concerning previous driving record requests made by others from such state agencies and state provide driving records.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED, TO FURNISH THE ABOVE MENTIONED INFORMATION.

I have the right, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me, which have been previously furnished within the three-year period preceding my request. I hereby consent to your obtaining the above information, and I agree that any information, obtained, including my employment history with you if I am hired, will be supplied to other companies requesting such.
I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.
In exchange for Meteor Express' consideration of my employment application, I agree not to file or pursue any complaints, claims, or legal actions of any kind against any organization or individual that provides work-related information about me to Meteor Express or its agents in accordance with the terms and intent of this release. I also agree not to file or pursue any complaints, claims, or legal actions against Meteor Express or any of its employees, representatives, or agents arising out of their efforts to obtain work-related information about me.

By clicking on submit I certify I am the above applicant and consider this action as my digital signature.