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