Driver Application

In compliance with federal and state equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, national origin, religion, sex (including pregnancy, childbirth, and related medical conditions), disability, age, citizenship status, genetic information, military status, veterans status and any other characteristic protected by federal, state and/or local law.

The selection process includes this application and possibly one or more interviews. If you are an individual with a disability, do you believe you might need a reasonable accommodation for any part of the application and/or selection process?
If yes, please explain the reasonable accommodation which you may require.

Applicant Information

* For CDL required driving positions: Are you 21 years of age or older?   
* For non CDL required driving positions: Are you 18 years of age or older?   
* EXPIRATION DATE OF PHYSICAL EXAMINATION PER FMCSRS:

* Current & Previous Three Years Addresses:




Additional Previous Addresses:

Please provide the three pieces of information requested above for each additional address within past three (3) years.
As we previously reported, FMCSA regulations require that applicants provide this information for three years, so failure to allow for this would be a problem.

* Have you worked for RoadEx America before?

If yes, give dates:

Education History:

Please indicate highest grade completed:
Grade school:  
College:  
Post-Graduate:  

Employment History:

Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self-employment periods, and all commercial driving experience for the past ten (10) years
From (Mo/Year)
To (Mo/Year)
Present or Last Employer
1





Were you subject to the FMCSRs while employed here?
 

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 C.F.R. Part 40?
 
2





Were you subject to the FMCSRs while employed here?
 

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 C.F.R. Part 40?
 
3





Were you subject to the FMCSRs while employed here?
 

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 C.F.R. Part 40?
 
Additional Employment History:
Please provide the nine pieces of information requested above for each additional employment position within past three (3) years, including any unemployment or self-employment periods, and for each commercial driving position within the past ten (10) years.
  I understand the work history disclosure requirements and have provided accurate information.

* Driving Experience:

Class of Equipment
From
To
Approx. # of Miles
Straight Truck
Tractor & Semi-trailer
Tractor & two trailers
Tractor & triple trailers
Other
* List states operated in, for the last five (5) years:
* List special courses/training completed (PTD/DDC, HAZMAT, etc.):
* List any Safe Driving Awards you hold and from whom:

* Accident Record for past three (3) years:

Date of Accident
Nature of Accident
Location of Accident
# of Fatalities
# of People Injured
Additional Accident Record Details:
Please provide the five pieces of information requested above for each additional accident within past three (3) years.

* List all violations of motor vehicle laws or ordinances (other than violations involving only parking) with respect to which you have been convicted or forfeited bond or collateral during the preceding 3 years.

Date
Location
Charge
Penalty
Additional Motor Vehicle Violations:
Please provide the four pieces of information requested above for each additional violation of motor vehicle laws or ordinances (other than violations involving only parking) with respect to which you have been convicted or forfeited bond or collateral during the preceding 3 years.

* Driver’s License (list each driver’s license held in the past three (3) years):

State
License No.
Type
Endorsements
Expiration Date

40 C.F.R. section 383.21 states that: “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license.”

  I certify that I do not have more than one motor vehicle license. information.
* Have you ever been denied a license, permit or privilege to operate a motor vehicle?   
If so, please write a statement explaining the facts and circumstances in detail:
* Has any license, permit or privilege ever been suspended or revoked?   
If so, please write a statement explaining the facts and circumstances in detail:
* Is there any reason you might be unable to perform the functions of the job for which you have applied (with or without a reasonable accommodation) based on your current understanding of the position?   
If so, please write a statement explaining the facts and circumstances in detail:

Background

Have you ever been convicted of a felony or misdemeanor (subject to limitations set forth below)?

Applicants should omit references to: (1) an arrest, detention, or disposition regarding any violation of law in which no conviction resulted; (2) misdemeanor convictions which have been dismissed upon completion of probation; (3) any convictions which have been judicially dismissed or ordered sealed, expunged, or statutorily eradicated pursuant to law; (4) any pre-trial or post-trial diversion program; and (5) convictions under California Health and Safety Code sections 11357(b) or (c), 11360(c), 11364, 11365 or 11550, or any statutory predecessor thereof, related to marijuana which occurred two or more years ago.

For applicants to be based in the State of Washington: Please also omit reference to (1) any convictions dating back more than 10 years and (2) any convictions not related to the job position you are applying for. If there are references to any arrests, please state, in the comments box above, whether the charges are still pending, have been dismissed, or led to the conviction of a crime involving behavior that would adversely affect job performance.

Applicants, more than fifty percent of whose duties are to be performed in the city of Seattle: Do not respond to this question at this time, but rather check "Yes" in the line below.   
Applicants whose duties are to be performed in whole or substantial part within San Francisco’s geographic limits: Do not respond to this question at this time, but rather check "Yes" in the line below.   
NOTE: A conviction or pending charge will not necessarily be a bar to employment. In assessing that record, the following factors will be taken into account: the nature and gravity of the offense or conduct, the time that has passed since the offense, any rehabilitation and the relationship of the offense to position sought.   

Response   
For each criminal conviction, the nature of the offense, the dates of incarceration, the sentence imposed, and any information about your rehabilitation and good conduct since the conviction:
* Can you provide proof of your identity and legal authorization to work in the United States?   

* Job References

List three (3) persons for references, other than family members, who have knowledge of your safety habits.

Name
Address
Phone

DISCLOSURE RE INVESTIGATION INTO EMPLOYMENT BACKGROUND

By checking the box below, I represent that I understand that as part of consideration of my application, the Federal Motor Carrier Safety Administration regulations require that RoadEx America, Inc. (“RoadEx America”) investigate my employment background. 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 well as my driving record and previous drug and alcohol test results, as required by the Federal Motor Carriers Safety Regulations, 49 C.F.R. 391.23(d) and (e). I understand that I have the right to:

  • Review information provided by current and previous employers;
  • Have errors in the information corrected by 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.
  I agree.

By checking the box below, I authorize RoadEx America to contact the employers listed on this application and I further authorize such employers to release any information concerning me as they deem appropriate. I release and forever discharge RoadEx America, its agents and employees, and the above named employers, their agents or employees, and any other party providing requested information to RoadEx America, from any and all liability, suits, or causes of action arising in any manner from RoadEx America contacting such employers or parties and/or from information provided in response to RoadEx America’s inquiry. I understand that this release prevents me from instituting any claim, lawsuit or other legal action based upon any information any employer or party may provide to RoadEx America.

  I agree.

I understand that I am applying for a job that may require that I transport loads in interstate commerce.

  I agree.

I understand that, as a condition of hiring, I will be required to submit to a pre-employment drug/alcohol test, and, if hired, thereafter be subject to drug and alcohol testing, pursuant to FMCSRs.

  I agree.

I understand and agree that, if I am employed by RoadEx America, my employment with RoadEx America will be on an “at will” basis, meaning that my employment can be terminated, with or without cause and with or without notice, at any time at the option of RoadEx America or at my option.

  I agree.

I understand and agree that, if employed by RoadEx America, I will sign a written Agreement to Arbitrate Disputes in accordance with then-current Employment Arbitration Rules and Mediation Procedures of the American Arbitration Association.

  I agree.

I understand and agree that typing my name below, and completing this online application, constitute my electronic signature, dated as of when I submit this application and that by doing so I acknowledge that the electronic signature contained on this document is authentic. I consent to the use of my electronic signature in completing this application, as well as the Authorization To Obtain Consumer and/or Investigative Consumer Reports below, and to receive the legal notices and disclosures set forth above and below.

  I agree.

* Signature of applicant:

* Please enter your birth date and month (DD/MM):

I CERTIFY THAT THAT THIS APPLICATION WAS COMPLETED BY ME, AND THAT ALL ENTRIES AND INFORMATION IN IT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. IF I AM EMPLOYED, I UNDERSTAND THAT ANY FALSE OR MISLEADING STATEMENTS ON THIS APPLICATION, OR DURING INTERVIEWS, SHALL BE CONSIDERED SUFFICIENT CAUSE FOR THE IMMEDIATE TERMINATION OF MY EMPLOYMENT.

  I agree.

NOTICE AND DISCLOSURE OF INTENT TO PROCURE CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORTS

This is to advise you that RoadEx America, Inc. (“RoadEx America”) will utilize the services of a consumer reporting agency as part of the procedure for processing your application for employment. This Notice is provided to you because RoadEx America may request consumer reports and/or investigative consumer reports in connection with your application for employment or during the course of your employment with RoadEx America, or for other employment-related purposes.

The types of reports that may be requested from consumer reporting agencies under this policy include, but are not limited to: credit reports, criminal records checks, court records checks, driving records and/or summaries of educational and employment records and histories.

The report may contain information on your character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about you which may reflect upon my potential for employment gathered from any individual. The information contained in these reports may be obtained by a consumer reporting agency from public record sources or through personal interviews with your co-workers, neighbors, friends, associates, current or former employers, or other personal acquaintances. Any information contained in such reports may be taken into consideration in evaluating your suitability for employment, promotion, reassignment or retention as an employee. You have the right to view the information compiled by the consumer reporting agency. You must authorize in writing the procurement of the report by signing below.

By checking the box below, I acknowledge that RoadEx America has provided me, at the following link, with a Summary Of My Rights Under The Federal Fair Credit Reporting Act.

I understand that if I want a paper copy of the Summary of My Rights Under the Federal Fair Credit Reporting Act, I may print it by opening the preceding link or I may request a copy during or after my interview.

  I agree.

I understand that if I want a paper copy of this Notice of Intent to Procure Consumer and/or Investigative Consumer Reports, I may print it by opening the preceding link or I may request a copy during or after my interview.

  I agree.

AUTHORIZATION TO OBTAIN CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORTS

I have carefully read and understand the above Notice Of Intent To Procure Consumer And/or Investigative Consumer Reports and this Authorization. I hereby authorize RoadEx America to obtain consumer and/or investigative consumer reports (1) in conjunction with my application for employment, and (2) during the course of my employment. I understand that RoadEx America and its agents are not responsible for the accuracy or completeness of the information contained in any such reports. I understand and agree that this Authorization will remain in effect indefinitely, until such time as I inform RoadEx America in writing that I am revoking this Authorization. I further understand that any and all information contained in my job application or otherwise disclosed to RoadEx America by me may be utilized for the purpose of obtaining the consumer reports or investigative consumer reports requested by RoadEx America.

* Signature of applicant:

  I agree.
* Are you applying to work in California?   

By checking the box below, I acknowledge that RoadEx America has provided me, at the following link, with the below Summary of Your Rights Under the Provisions of California Civil Code Section 1786.22.

  I agree.

I understand that if I want a paper copy of the above Summary of Your Rights Under the Provisions of California Civil Code Section 1786.22 I may print it by opening the preceding link or I may request a copy during or after my interview.

  I agree.
By checking "Yes" in the line below, I am requesting a copy of any consumer and/or investigative consumer report from the consumer reporting agency at no extra charge at the same time the report is provided to the employer.