Z Mix Drivers Application

Hidden

Date of Application

Personal Information

Name*

First Middle Last

Are you 21 years or older?*

Yes
No

Birth Date*

Social Security Number*

You MUST be 21 years or older to be eligible for a CDL required position.

Current Address*

Street Address City State ZIP

How many years have you lived at your current address?*

Cell Phone Number*

Home/Other Phone Number

Email Address*

Are you a U.S. citizen or otherwise currently authorized to obtain lawful employment in this country?*

Yes
No

Have you pleaded guilty to or been convicted of a misdemeanor or felony?*

We will consider your record only as it may substantially relate to the job for which you are applying.

Yes
No

Provide further information as to the offense(s), date, location, and so forth.*

Employment Desired

Position Applied For*

Salary/Hourly Rate

Date You Can Start*

Have you ever applied to this company before?*

Yes
No

Season previously applied*

Year previously applied*

Education and Training

High School

Name and Location of School	Number of years attended	Graduate?

College

Name and Location of School	Number of years attended	Graduate?	Subject Studied/Degree

Technical/Trade School

Name and Location of School	Number of years attended	Graduate?	Subject Studied/Degree

Driving Qualifications and Experience

Do you have a valid Commercial Drivers License?*

Yes
No

A Commercial Drives License is required for a CDL position.

Drivers License Information

State	License Number	Type	Expiration Date (mm/dd/yyyy)

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

Yes
No

Has any license, permit, or privilege ever been suspended or revoked?*

Yes
No

Explain why your license, permit, or privilege was denied, suspended, or revoked.*

Driving Experience

Vehicle/Equipment Type	Type of Trailer	Start Date	End Date

Did you specify 'Other' for any Driving Experience entires?*

Yes
No

Please specify the 'Other Vehicle/Equipment' and/or 'Other Trailer' listed in your driving experience.

Traffic Convictions

List all violations for the past 3 years (excluded parking violations)

Location	Date	Charge	Penalty

Accident Record

List all accidents for the past 3 years or more

Date	Nature of Accident (head-on, rear-end, upset, etc.)	Damages	Injuries	Fatalities

Driving Abstract History

I am unsure of the exact date of any violations and accidents, please see my Driving Abstract History.

Employment Record

DOT requires that employment for at least 3 years and commercial driving for the past 10 years be shown. Provide complete information. Be specific. Include self-employment and military service. For part-time work, show the average number of hours per month.

Are you currently employed?*

Yes
No

May we contact your current employer?*

Yes
No

Current/Most Recent Previous Employer
Employer Name
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Name of Supervisor
Phone
Position Held
Last Pay Rate
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Duties
Reason for leaving
While employed for this company, were you subject to Federal Motor Carrier Safety Regulations (FMCSRs)?*
- Yes
- No
Was your position a safety sensitive function and therefor subject to the DOT-regulated alcohol and controlled substance testing requirements?*
- Yes
- No

Do you need to add a second previous employer?*

Yes
No

Second Most Recent Previous Employer
Employer Name
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Name of Supervisor
Phone
Position Held
Last Pay Rate
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Duties
Reason for leaving
While employed for this company, were you subject to Federal Motor Carrier Safety Regulations (FMCSRs)?
- Yes
- No
Was your position a safety sensitive function and therefor subject to the DOT-regulated alcohol and controlled substance testing requirements?
- Yes
- No

Do you need to add a third previous employer?*

Yes
No

Third Most Recent Previous Employer
Employer Name
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Name of Supervisor
Phone
Position Held
Last Pay Rate
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Duties
Reason for leaving
While employed for this company, were you subject to Federal Motor Carrier Safety Regulations (FMCSRs)?
- Yes
- No
Was your position a safety sensitive function and therefor subject to the DOT-regulated alcohol and controlled substance testing requirements?
- Yes
- No

Do you need to add a fourth previous employer?*

Yes
No

Fourth Most Recent Previous Employer
Employer Name
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Name of Supervisor
Phone
Position Held
Last Pay Rate
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Duties
Reason for leaving
While employed for this company, were you subject to Federal Motor Carrier Safety Regulations (FMCSRs)?
- Yes
- No
Was your position a safety sensitive function and therefor subject to the DOT-regulated alcohol and controlled substance testing requirements?
- Yes
- No

Do you need to add a fifth previous employer?*

Yes
No

Fifth Most Recent Previous Employer
Employer Name
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Name of Supervisor
Phone
Position Held
Last Pay Rate
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Duties
Reason for leaving
While employed for this company, were you subject to Federal Motor Carrier Safety Regulations (FMCSRs)?
- Yes
- No
Was your position a safety sensitive function and therefor subject to the DOT-regulated alcohol and controlled substance testing requirements?
- Yes
- No

Do you need to add any additional employment history?*

Yes
No

Enter additional Employment History.

Additional Personal Information for Background Screening

Maiden or other names used.

Name Changed	Previous Name Used	Date Changed

Gender*

Male
Female
Prefer Not to Answer

Previous Addresses

List all addresses where you have lived for the past 7 years.

Street Address	City	County	State	Zip	For How Long?

References

Personal References

List at least three personal references that are not related to you.

Name	City, State	Phone Number	Years Acquainted

Notification to Applicant

AS A PROSPECTIVE EMPLOYER WE ARE REQUIRED TO INFORM ALL DRIVER APPLICANTS THAT THE INFORMATION PROVIDED ON THIS APPLICATION OF EMPLOYMENT MAY BE USED, AND APPLICANTS' PRIOR EMPLOYERS MAY BE CONTACTED, FOR THE PURPOSE OF INVESTIGATING THE SAFETY PERFORMANCE HISTORY INFORMATION AS REQUIRED BY PARAGRAPHS(D) AND (E) OF 49 CFR.391.23 OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS (FMCRs). AS THE PROSPECTIVE EMPLOYER, WE MUST ALSO NOTIFY DRIVER APPLICANTS OF THEIR DUE PROCESS RIGHTS AS SPECIFIED IN 49 CFR.391.23(I) OF THE FMCRs REGARDING INFORMATION RECEIVED AS A RESULT OF THESE INVESTIGATIONS.

DRIVER APPLICANT'S DUE RIGHTS INCLUDE THE RIGHT TO:

REVIEW INFORMATION PROVIDED BY PREVIOUS EMPLOYERS.
HAVE ERRORS IN THE INFORMATION CORRECTED BY THE PREVIOUS EMPLOYER AND FOR THAT PREVIOUS EMPLOYER 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 AND THE DRIVER CANNOT AGREE ON THE ACCURACY OF THE INFORMATION.

Authorization, Release, and Certification by Applicant

I CERTIFY THAT ALL INFORMATION ON THIS APPLICATION IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE OR MISLEADING STATEMENTS BY ME MAY RESULT IN REJECTION OF MY APPLICATION, OR, IF EMPLOYED, MY IMMEDIATE DISMISSAL.

I HEREBY GIVE PERMISSION OF TO THE EMPLOYER TO SEEK TO VERIFY AND SUPPLEMENT THE INFORMATION SET FORTH IN THE APPLICATION. I RELEASE FROM ALL LIABILITY OR LEGAL CLAIMS EVERY PERSON SEEKING OR PROVIDING INFORMATION, WHETHER ORAL OR WRITTEN. A PHOTOCOPY OF THIS RELEASE SHALL BE AS VALID AS THE ORIGINAL AND MAY BE RELIED UPON BY ALL PERSONS PROVIDING INFORMATION.

I UNDERSTAND THAT EMPLOYMENT WITH THIS EMPLOYER IS NOT CONTRACTUAL AND IS AT-WILL. I UNDERSTAND AND AGREE THAT, IF HIRED, I MAY VOLUNTARILY LEAVE EMPLOYMENT AT ANYTIME AND MAY BE TERMINATED AT ANYTIME WITHOUT PRIOR NOTICE FOR ANY REASON, OR FOR NO REASON. I UNDERSTAND THAT ANY ORAL OR WRITTEN STATEMENTS WHICH I MAY CLAIM TO HAVE BEEN MADE TO ME NOW OR IN THE FUTURE INCONSISTENT WITH THE PROVISIONS OF THIS PARAGRAPH, ARE EXPRESSLY DISAVOWED AND REVOKED BY THE COMPANY, AND SHOULD NOT BE RELIED UPON BY ME AS AN APPLICANT FOR EMPLOYMENT OR AS AN EMPLOYEE IF HIRED.

I UNDERSTAND THIS APPLICATION WILL BE CONSIDERED INACTIVE AFTER 30 DAYS.
I UNDERSTAND THAT IF MY APPLICATION IS ACCEPTED AND I AM OFFERED EMPLOYMENT, THE EMPLOYER MAY CONDITION EMPLOYMENT UPON MY HAVING A VALID FEDERAL MEDICAL CARD/DOT COMMERCIAL DRIVER PHYSICAL, AND IF IT IS EXPIRED, EMPLOYMENT IS CONDITIONED UPON THE SUCCESSFUL COMPLETION OF THIS COMMERCIAL DRIVERS DOT PHYSICAL, WHICH I AM FINANCIALLY RESPONSIBLE FOR.
I CERTIFY I HAVE READ AND UNDERSTAND THIS AUTHORIZATION, RELEASE, AND CERTIFICATION.

Type your name as acceptance.*

What is 6 + 2?*