BARRETT TRUCKING, LLC
Driver's Application for Employment
 
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, marital status, or non-job related disability.
 
Date of application :       
Position(s) Applied for :
Name:
Last
First
Middle		 Soc. Security # 
Address:
Street
City
State
Zip
Phone: How Long?
 
Addresses for the Past Three Years
Address:
Street
City
State
Zip
How Long?
Address:
Street
City
State
Zip
How Long?
Address:
Street
City
State
Zip
How Long?
Do you have the legal right to work in the United States?     
Date of Birth / / Can you provide proof of age?  
Are you now employed?   If so, where?  
If not, how long since leaving last employment?  
Reason for Leaving  
Who referred you?     Rate of pay expected  

EMPLOYMENT HISTORY
 
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years.
Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such a vehicle. ( NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary. )
Employer Name       
Employment    From    To    
Address:
Street
City
State
Zip
Position Held   
Salary / Wage  
Contact Person and Phone #  
Were you subject to the FMCSR (Federal Motor Carrier Safety Regulations) while employed here?
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements?         
Reason for leaving   
 
Employer Name       
Employment    From    To    
Address:
Street
City
State
Zip
Position Held   
Salary / Wage  
Contact Person and Phone #  
Were you subject to the FMCSR (Federal Motor Carrier Safety Regulations) while employed here?
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements?         
Reason for leaving   
 
Employer Name       
Employment    From    To    
Address:
Street
City
State
Zip
Position Held   
Salary / Wage  
Contact Person and Phone #  
Were you subject to the FMCSR (Federal Motor Carrier Safety Regulations) while employed here?
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements?         
Reason for leaving   
 
Employer Name       
Employment    From    To    
Address:
Street
City
State
Zip
Position Held   
Salary / Wage  
Contact Person and Phone #  
Were you subject to the FMCSR (Federal Motor Carrier Safety Regulations) while employed here?
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements?         
Reason for leaving   
 
Employer Name       
Employment    From    To    
Address:
Street
City
State
Zip
Position Held   
Salary / Wage  
Contact Person and Phone #  
Were you subject to the FMCSR (Federal Motor Carrier Safety Regulations) while employed here?
Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements?         
Reason for leaving   
 
* Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

Accident Record for past 3 years or more
(Add another sheet as necessary)
Dates
(Most recent accident first)		 Nature of Accident
(Head-on, Rear-end, Upset, etc.)		 Fatalities Injuries

Traffic Convictions and Forfeitures for the past 3 years  (other than parking violations)
(Add another sheet as necessary)
Location Date Charge Penalty

Do you have any felony convictions on your record? Yes  No
Do you have any charges pending for, or have you been, convicted of driving under the influence? Yes  No
Has your license or privilege to operate a motor vehicle ever been denied? Yes  No
Do you have any license or permit suspensions on your record? Yes  No
Do you have any charges pending or have you ever been convicted for reckless or carless operation of a motor vehicle? Yes  No
Do you have any charges pending for, or have you ever been convicted of possession, sale, or use of drugs? Yes  No
Have you ever been refused any type of insurance or been denied bonding? Yes  No
Have you ever been discharged or suspended? Yes  No
Has any license, permit or privilege ever been suspended or revoked? Yes  No
(If the answer to any of these questions is YES, attach a statement giving details.)

Education
 
Circle Highest Grade Completed:     1 2 3 4 5 6 7 8  
High School:     1 2 3 4   College:     1 2 3 4  
Last School Attended:
Name
City
State

Driving Experience
Experience and Qualifications - Driver

Driver
Licenses		 State License Number Type Expiration Date

Class of Equipment Type of Equipment
(van, tank , flat, etc.)		 Dates
From To
                   		 Approx. # of Miles (total)
Straight Truck
Tractor & Semi
Tractor & 2 trailers
Other

List states operated in for last five years  
List special courses or training that will help you as a driver  
Which safe driving awards do you hold and from who?  

Experience and Qualifications - Other
List any trucking, transportation or other experience that may help in your work Barrett Trucking, LLC.
List courses and training other than shown elsewhere in this application
List special equipment or technical materials you can work with (other than those already shown)
 
Have you ever collected Worker's Compensation? Yes   No

Have you ever had an injury in the past that could re-occur during your employment here?

 Yes   No
Have you ever been refused employment due to an injury? Yes   No
Do you have any medical problems now? Yes   No
Do you take any medications? Yes   No
Have you ever lied about an injury or Worker's Compensation information on any previous employment application? Yes   No
If you answered YES to any of the above questions you MUST explain below (Add another sheet as necessary).

To Be Read and Signed by Applicant
 
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. I authorize Barrett Trucking¸ LLC to make such investigations and inquiries of my personal, employment, and financial or medical history, and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of Barrett Trucking, LLC.
 
 

Applicant Signature
Date