wform

We currently have openings for: "Over The Road Truck Drivers"

Please Complete and Print This Form - Then Mail or Fax It To 712-947-4890

Application For Qualification Weinrich Truck Line, Inc. P.O. Box 1022, 27932 C60 Hinton, IA 51024

The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and Weinrich Truck Line, Inc.

Instructions to Applicant

Please answer all questions. If the answer to any question is "No" or "None", do not leave the item blank, but write "No" or "None"

*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but not less than 70 years of age.

Todays Date: Check One: Driver Contractor

Have you ever applied to this company before? Yes NoIf Yes, When

Name Date Of Birth

Phone Number Emergency Phone Number

*Age S.S.Number Physical Exam Expiration Date

Current & Three Years Previous Address: From: To:

Education and Employment History

Please fill in the highest grade completed:

Grade School: College: Post Graduate:

Give a complete record of all employment for the past three years, including any unemployment or self-employment, and all commercial driving experience for the past ten years. If additional pages are needed, please attach.

Current Employer:

Dates of Employment: Name of Company: From: To: -

Position Held: Address

Reason For Leaving Phone #

Were you subject to the FMCSR's while employed here? Yes No

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No

Next Employer:

Dates of Employment: Name of Company: From: To: -

Position Held: Address

Reason For Leaving Phone #

Were you subject to the FMCSR's while employed here? Yes No

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No

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Next Employer:

Dates of Employment: Name of Company: From: To: -

Position Held: Address

Reason For Leaving Phone #

Were you subject to the FMCSR's while employed here? Yes No

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No

Next Employer:

Dates of Employment: Name of Company: From: To: -

Position Held: Address

Reason For Leaving Phone #

Were you subject to the FMCSR's while employed here? Yes No

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No

Next Employer:

Dates of Employment: Name of Company: From: To: -

Position Held: Address

Reason For Leaving Phone #

Were you subject to the FMCSR's while employed here? Yes No

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No

Driving Experience

Class of Equipment Dates: From - To Approximate Total Miles

Tractor-Trailer -

Dry Van -

Tanker -

Other -

List types of trucks driven and transmissions driven:

List states operated in for the last five years:

List special courses/training completed (PTD/DDC, Haz Mat, Etc.)

List any Safe Driving Awards you hold and from whom:

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Accident Record for past three years

Date Of Nature of Location Of # of # of Accident Accident Accident Fatalities Injuries

Traffic Convictions and Forfeitures for the last 5 years (other than parking violations)

Date Location Charge Penalty

Driver's License (list each driver's license held in the past three years)

State License # Type Endorsements Expiration Date

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

B. Has any license, permit or privilege ever been suspended or revoded? YesNo

C. Have you ever been convicted of a felony? Yes No

D. Have you ever tested positive or refused a DOT Drug or Alcohol pre-employment test within the past two years from an employer who did or did not hire you? Yes No

If the answers to A, B, C or D is Yes, give details

Personal References

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

NameAddressPhone

How did you hear about our company and / or who referred you to our company?

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To be read and SIGNED by Applicant

It is agreed and understood that any misrepresentations given on this application for qualification shall be considered an act of dishonesty.

I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background, I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me.

It is agreed and understood that if qualified to operate motor carrier equipment, I may be on a probationary period, during which I may be disquallified 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.

Applicants Signature Date

DO NOT WRITE BELOW THIS SPACE

Remarks (for office use only)

Company official's that revied this application

Safety Date

Operations Date

Management Date

Actual hire date of this applicant

Rate of pay this driver was started at: Date of next possible raise

Which driver if any receives referral bonus When

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Request for Driver's Safety Performance History

Information from DOT Regulated Previous Employer

WEINRICH TRUCK LINE, INC.

Steve Farrer / Safety

27932 C 60

Hinton, IA 51024

Phone: 712-947-4887 Fax: 712-947-4890

Driver to Complete This Section

As a Commercial Motor Vehicle (CMV) Driver, I understand that per, the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391.21, the following information will be requested from all previous employers for which I operated a CMV, subject to the FMCSR Parts 390and/or 40, 382 & 383, within the past three years, from the date shown below, I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part 391.23.

I , hereby authorize this company to release all records of employment, including assessments of my job performance, ability and fitness, including dates of any and all alcohol or drug tests. Those confirmed results and/or my refusal to submit to any alcohol or drug tests and any rehabiltation completion under direction of (SAP/MRO) to each and every company (or their quthorized agents) which may request such information in connection with my application for employment with said company. I hereby release this company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing information to the above-mentioned person adn/or company.

Previous Employer: Contact Person:

Mailing Address: City, State, Zip:

Telephone Number: Fax Number:

I worked for this company from the dates of / / to / /

Applicants Signature SSN or ID Number D.O.B. Today's Date

SECTION I -- Past Employer to Complete >>> DRUG AND ALCOHOL INFORMATION

Please provide the following drug and alcohol information as required by FMCSR Part 391.23 & 40.25

If no drug and alcohol information is available on above-named applicant check here. Yes No

1. Any alcohol test with a result of 0.04 or higher alcohol concentration?

2. Any verified positive drug test?

3. Any refusals to be tested (including verified adulterated or substituted drug test results)?

4. Any other violations of DOT agency drug and alcohol testing regulations (Part 382 or Part 40)?

5. If this driver did successfully complete a SAP rehabilitation referral and remained in your employ, did he/she have any subsequent violations for: an alcohol test result of 0.04 or greater, a verified positive drug test or a refusal to test (including a verified adulterated/substituted drug test result)?

6. If yes to any of the above questions, please provide documentation of successful completion of a SAP evaluation, prescribed treatment and return-to-duty requirements (including follow-up tests) if they remained in your employ.*

*If this information is not available from the previous employer, you as a prospective employer, must get this information from the driver/applicant.

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Disclosure and Release

In connection with my application for employment (including contract services) with you, I understand that consumer reports, which may contain public record information, may be requested from DAC Services in Tulsa, OK. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers compensation claoms, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from DAC concerning previous driving record requests made by others from such agencies, and state provided driving records.

I also understand that a claims history report may be requested from our insurance company. This report may include the following information with regard to my driving history, accident dates, state of accident location, and a brief description of the accident.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY DAC OR OUR INSURANCE COMPANY TO FURNISH THE ABOVE MENTIONED INFORMATION.

I have the right to make a request to DAC, 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 DAC has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that such information, which DAC has or obtains, and my employment history with you, if I am hired, will be supplied by DAC to other companies, which subscribe to DAC services.

I also have the right to make a request to the employers insurance company, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request.

I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and serve as an ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

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 the reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

Print Name Social Security Number

Applicant's Signature Date

Please Print This Form And Sign All The Appropriate Places

And Mail or Fax It To 712-947-4890

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