Driver Application Form

INSTRUCTIONS: Complete all portions of this form. If a portion does not apply, write N/A or NONE in the space. Application must be filled out in full, resumes will not be accepted.
  • xxx-xx-xxxx
  • City, State
  • Name, Driver # or Location
  • DRIVING PREFERENCES

  • MILITARY SERVICE RECORD

  • TRAINING

    List any training program presently attending or completed (truck driving schools, service schools, etc.)
  • MOTOR VEHICLE LICENSES

    List all driver licenses held in the last FIVE years (Included multiple licenses il you have them)
  • ACCIDENT RECORD

    List all accident involvements with any vehicle lor the past FIVE years (even iF not at Faul/Or write NONE)
  • (MM/DD/YY)
  • (MM/DD/YY)
  • (MM/DD/YY)
  • PERSONAL HISTORY FOR PAST 10 YEARS

  • List all Motor Carriers employed with for the previous 10 years and all employers for the last 10 years. If business has closed or no contact information is given, you must present W2. 1099 or paycheck stubs as proof of employment
  • (MMlYY)
  • (MMlYY)
  • (month or Year)
  • (MMlYY)
  • (MMlYY)
  • (month or Year)
  • (MMlYY)
  • (MMlYY)
  • (month or Year)
  • (MMlYY)
  • (MMlYY)
  • (month or Year)
  • (MMlYY)
  • (MMlYY)
  • (month or Year)
  • (MMlYY)
  • (MMlYY)
  • (month or Year)
  • (MMlYY)
  • (MMlYY)
  • (month or Year)
  • TRAFFIC CONVICTIONS (If none, write NONE)

    List all traffic convictions for the past FIVE years (In any motor vehicle, other than parking violations)
  • (Month/Year)
  • State or Country if Outside of U.S.
  • (If speeding, show rate of speed)
  • (Of Fine)
  • (Month/Year)
  • State or Country if Outside of U.S.
  • (If speeding, show rate of speed)
  • (Of Fine)
  • (Month/Year)
  • State or Country if Outside of U.S.
  • (If speeding, show rate of speed)
  • (Of Fine)
  • RECORD OF CONVICTIONS, DEFERRED PROSECUTIONS AND PENDING CHARGES

    List all felonies of which you have ever been convicted; and all misdemeanors within the last FIVE years that you have pled "guilty" to, been convicted of, had prosecution deferred in connection with, or pled "no contest" to (If none, write NONE)
  • (Month/Year)
  • (City, State, County, Country)
  • (If speeding, show rate of speed)
  • (Month/Year)
  • (City, State, County, Country)
  • (If speeding, show rate of speed)
  • (Month/Year)
  • (City, State, County, Country)
  • (If speeding, show rate of speed)
  • List all unresolved charges pending in the judicial system (if none, write NONE)
  • (Month/Year)
  • (City, State, County, Country)
  • (If speeding, show rate of speed)
  • (Month/Year)
  • (City, State, County, Country)
  • (If speeding, show rate of speed)
  • (Month/Year)
  • (City, State, County, Country)
  • (If speeding, show rate of speed)
  • PHYSICAL REQUIREMENTS FOR POSITION

  • All applicants must meet the D.O.T. and Navajo physical qualification requirements. Are you physically able, with or without a reasonable accommodation
  • ACKNOWLEDGEMENT

  • I authorize Navajo Express, Inc (the Company) to investigate all job-related information pertaining to me. I release the Company and its representatives from any liability that may arise as a result of the investigation. I also relase all other persons, corporations or organizations from any liability that may arise from providing the Company with requested job-related information. (A copy of this page serves as my authorization to seek or provide information). I agree to sign any documents and consent forms that the Company deems necessary to verify the facts provided in the application and other documents provided to me.

    I realize as a condition of my employment I will be required to undergo a post offer/pre-employment medical examination and substance abuse screening at the expense of and as prescribed by the Company and that any offer of employment is conditioned upon the successful completion of the tests. I agree to furnish such additional information and undergo any other examinations or tests to include random alcohol and substance abuse screening tests which may be required to complete the employment file or continue my employment with the Company if employed. Further. I release the Company, its agents or employees from any and all claims or actions arising out of such alcohol and substance abuse tests including but not limited to, the testing procedures, the analysis or the disclosure of test results.

    I understand and agree that any offer of employment is contingent upon my ability to produce documentation verifying my identity and legal authorization to be employed, as required by Federal Law.

    I understand and agree that any misrepresented, inaccurate, misleading, incomplete or omitted information provided by me in this application will be sufficient cause for cancellation of this application and/or separation from the Company's service. If employed further, I understand that just as I am free to resign at any time, for any reason with or without prior notice, the Company reserves the right to terminate my employment at any time, for any reason, with or without prior notice. I understand that no representatives of the Company have the authority to make any verbal or written assurances to the contrary. I recognize the employment relationship to be an at will relationship and not for a specific period of time. This application represents the complete and final expression of the intent of the parties.

    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

  • EMPLOYMENT GAP SHEET

  • List all Gaps in employment for the past TEN years:
  • Can be verified by:
  • Can be verified by:
  • Can be verified by:
  • DAC ORDER FORM

  • Please complete the following:
  • XXX-XX-XXXX
  • DOT DRUG/ALCOHOL DISCLOSURE AND AUTHORIZATION

  • PART I - DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES 49 CFR PART 391.23. DOT DRUG AND ALCOHOL TESTING

    In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to USIS for the purpose of USIS transmitting such records to the USIS customer listed above. I understand that information/documents released pursuant to this Part I is limited to the following DOT -regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation.

    If any company listed below furnishes USIS with infonmation concerning items (i) through (vi) above, I also authorize such company to furnish the following information to USIS, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years

    .

    List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years.

  • XXX-XX-XXXX
  • PART II - CONSUMER REPORT AND INVESTIGATIVE CONSUMER REPORT DISCLOSURE (FOR EMPLOYMENT PURPOSES)

  • In connection with your employment or application for employment (including contract for services) and in accordance with applicable laws, USIS may obtain or assemble consumer reports and/or investigative consumer reports (collectively, "Reports") which may include information about you related to: previous employment (including employers, dates of employment, salary information, reasons for termination, etc.), accident history, academic history, verification of references and other information supplied by applicant, professional credentials, drug/alcohol use in violation of law and/or company policy, driving record, workers' compensation claims, credit history, creditworthiness, credit capacity, bankruptcy filings, criminal history records, information about your character, general reputation, personal characteristics and mode of living (collectively, "Information"). Information may be obtained from government agencies, educational institutions, USIS clients, personal references, personal interviews and other Information suppliers (collectively, "Suppliers").

    Upon providing proper identification and complying with any applicable legal requirements, you have the right to request the nature and substance of all Information in USIS's files pertaining to you at the time of your request, including but not limited to: (i) whether any Reports have been provided by USIS to other parties; (ii) identification of any Suppliers utilized by USIS in compiling such Reports; and (iii) identification of any recipients of Reports furnished by USIS within the two (2) year period preceding your request. US IS may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma, 74153, or by phone at (800) 381-0645.

  • PART II - AUTHORIZATION FOR RELEASE OF INFORMATION (FOR EMPLOYMENT PURPOSES)


    I hereby authorize USIS to receive Information and disclose such Information to its customers for the purpose of making a determination as to my eligibility for employment, promotion, retention or other lawful purpose. If hired or contracted, I authorize USIS and the USIS customer named above ("Customer") to retain this document on file to act as ongoing authorization for the procurement and possession of Reports at any time during my employment or contract period. I fully release USIS and Suppliers from all claims of damages related to the investigation of my background and provision of Information as set forth in this disclosure and authorization. I agree that Information in USIS's possession and my employment history with Customer if I am hired, may be supplied by USIS to other USIS customers for legally permissible purposes; provided, such Information will not include the Drug and Alcohol information set forth in Part I above, unless I have given a separate specific consent for USIS to share such Information.

    By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part II disclosure and authorization for release; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the Information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; (vi) I authorize USIS and any person or entity contacted by USIS to furnish the above mentioned Information; and (vii) facsimile or photographic copies of this authorization are as valid as an original.

    NOTE - THIS AUTHORIZATION DOES NOT APPLY TO DRUG & ALCOHOL INFO ADDRESSED IN PART I.

  • XXX-XX-XXXX