Driver Application Form

Applicant: please read and accept the following, prior to submitting this application for qualification.
(A) The information you provide in this application, including but not limited to the information required by 49 CFR 391.21(b)(10)(11) below may be used, and your previous employers(s) will be contacted, for the purpose of investigating your safety performance history as required by 49 CFR 391.23(d)(e) and 49 CFR 40.25 (re: drug and alcohol information).
(B) The prospective motor carrier, Gainey Transportation Services, Inc., hereby notifies you that you have the following rights regarding the investigative information that will be provided to us pursuant to 49 CFR 391.23(d)(e):
(1) The right to review information provide to us by previous employers/motor carriers;
(2) The right to have errors in the information provided to us by the previous employer/motor carrier and for that previous employer/motor carrier to re-send the corrected information to Gainey Transportation Services, Inc.;
(3) The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer/motor carrier and you cannot agree to the accuracy of the information.
(C) EQUAL OPPORTUNITY EMPLOYER: In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, disability, and in Michigan, height, weight, and marital status.
(D) I understand that if I have a protected handicap that effects my ability to perform the position, I may ask Gainey Transportation Services, Inc. to attempt to make accommodation as required by law. I must make my request in writing to Gainey Transportation Services, Inc. as soon as possible and no later than 182 days after the date I know or reasonably should know that accommodation is needed.
I have read and accept the information above:
Personal Information
First Name:  
Last Name:  
Address (line 1):  
Address (line 2):  
City:  
State:  
Zip Code:  
Date of Birth:  
Social Security Number:  
Telephone Number:  
Cell Phone Number:  
Email Address:  

Drivers License
License Number:  
State Issued:  
Expiration Date:  

Driving Record
Do you have a class A CDL?   Yes No
Total Years of OTR Driving:  
Number of tickets in the last 3 years:  
Number of accidents in the last 3 years:  
Have any licenses, permits, or privileges ever been suspended or revoked?
 		   Yes No
  If yes, please explain:
Have you ever been convicted of or are any charges pending for driving while under the influence of alcohol, a narcotic drug, amphetamines or derivatives thereof?
 		   Yes No
  If yes, please explain:
Have you ever been convicted of or are any felony charges pending against you?   Yes No
  If yes, please explain:

Last Employer Information
Name  
Phone Number  
Address  
City  
State  
Zip Code  
Position Held  
Date Hired  
Date Left  
Salary  
Reason for Leaving  
If you were a driver, complete the following:
Equipment:     Division:  

2nd to Last Employer Information
Name  
Phone Number  
Address  
City  
State  
Zip Code  
Position Held  
Date Hired  
Date Left  
Salary  
Reason for Leaving  
If you were a driver, complete the following:
Equipment:     Division:  

3rd to Last Employer Information
Name  
Phone Number  
Address  
City  
State  
Zip Code  
Position Held  
Date Hired  
Date Left  
Salary  
Reason for Leaving  
If you were a driver, complete the following:
Equipment:     Division: