Click Here To Apply! - Albion Motor Services

Date *

Available Start Date *

Name *

First

Middle

Last

Phone Number *

Do not use a hyphen (-)

Date of Birth

Social Security Number *

License Information *

List the State, License Number, Type/Class, Endorsements & Expiration of your drivers license.

Motor Vehicle & Criminal Record Release Consent *

By selecting “Yes” you give permission to Albion Motor Services to use your SSN & Drivers License number to perform a full background check. This consent is given in satisfaction of Public Law 18 USC 2721 et. Seq., “Federal Drivers Privacy Protection Act”, and is intended to constitute “written consent” as required by this Act.

Email *

Do you have the legal right to work in the United States? *

Residential Address *

List your current address as well as any addresses from the previous 3 years. Must be in the following format; 1234 Pennsylvania Ave Cleveland, OH 44129 – 2.5 Years

Address 2

Address 3

Commercial Driving Experience *

Do you have commercial driving experience?

If yes, please list the following information about your experience:

Please include the following: Class (ex. straight truck, tractor trailer), Type of equipment (ex. dry van, flatbed, tanker) Dates & Approximate Miles Driven.

Have you had any traffic accidents in the last three years? *

If yes, please list the following information about any accidents you have had:

With the most recent first. Dates, Nature (head on, rear end, turn over), Number of injuries or fatalities, at fault or victim.

Have you had any traffic convictions or license suspensions in the last 3 years? *

If yes, please list the following information about any traffic convictions or license suspensions you have had:

Conviction date, Type of traffic violation, State of conviction, Penalty of conviction.

Have you ever been denied a license, permit, or privilege to operate a motor vehicle? *

If yes, please explain.

Employment History

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information

Employer 1 Name & Phone Number *

List your most recent employers name and phone number.

Address *

List the address of a previous employer.

Position Held *

List your position at your previous employer.

Dates Employed *

When did you work for your previous employer?

Salary

Selected Value: 0

What was your salary while employed here?

Reason For Leaving *

Why did your employment end?

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? *

Employer 2 Name & Phone Number

List your employers name and phone number.

Address

List the address of a previous employer.

Position Held

List your position at your previous employer.

Dates Employed

When did you work for your previous employer?

Salary

Selected Value: 0

What was your salary while employed here?

Reason For Leaving

Why did your employment end?

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Employer 3 Name & Phone Number

List your employers name and phone number.

Address

List the address of a previous employer.

Position Held

List your position at your previous employer.

Dates Employed

When did you work for your previous employer?

Salary

Selected Value: 0

What was your salary while employed here?

Reason For Leaving

Why did your employment end?

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Employment History Gaps

Use this section to explain any gaps in your listed work history within the last 3 – 10 years.

Did you graduate? *

Please list any other qualifications that you have and which you believe should be considered.

TO BE READ AND SIGNED BY APPLICANT *

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to: •Review information provided by current/previous employers; •Have errors in the information corrected by previous employers, and for those previous employers to resend thecorrected information to the prospective employer; and •Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannotagree on the accuracy of the information. This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.