Drivers

DRIVER'S APPLICATION FOR EMPLOYMENT

Phone 402-731-5047, 800-228-1008, Fax 402-731-8163
Zeitner and Sons, Inc.
5516 South 27th Street P.O. Box 7760
Omaha, NEĀ  68107
dena@zeitnerandsons.com

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, veterans status, non-job related disability or any other protected group status.

* Denotes Required field

List your addresses of residency for the past 3 years.

Current Address

Previous Address

If yes, please explain on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.

Employment History

All driver applicants intending to operate a vehicle in interstate commerce requiring a commercial driver's license (CDL) must provide a total of 10 years employment history for which he/she operated a commercial motor vehicle. List complete mailing address, street, city, state and zip code. (Note: List employers in reverse order starting with the most recent. Add another sheet if necessary.)

Add Employer

The FMCSA apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the (1) vehicle weights or has a GVWR of 10,001 pounds or more, (2) is designed to transport 9 or more passengers, (3) is of any size & is used to transport HM in placarding quantities.

ACCIDENT HISTORY

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE(ATTACH SHEET IF MORE SPACE IS NEEDED)IF NONE, WRITE NONE

Add Accident

MOVING VIOLATIONS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS(OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

Add Moving Violation

EDUCATION

name / city / state

EXPERIENCE AND QUALIFICTIONS - DRIVER

DRIVER LICENSES

DRIVING EXPERIENCE

CHECK YES OR NO

Class of Equipment

Equipment Type

From (M/Y) / TO (M/Y)

Approx. No. of Miles

Van,Tank,Flat,Reefer

Van,Tank,Flat,Reefer

Van,Tank,Flat,Reefer

Van,Tank,Flat,Reefer

More than 7 passengers

More than 15 passengers

EXPERIENCE AND QUALIFICATIONS - OTHER

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquires 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 of Zeitner and Sons, Inc. company policies.

I understand that information I provide regarding current and/or previous employer(s) may be used and those employer(s) will be contacted, for the purpose of investigation of my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

  • Review information provided by previous employers:
  • Have errors in the information corrected by previous employers and those previous employers to resend the corrected information to the prospective employer; and
  • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of my knowledge.

What kind of work did he/she do?

If you answered yes to any of the above questions, please give name, address and telephone number of the Employee Substance Abuse Program (ESAP) used.

TRUCKING INDUSTRY:
DOT D/A Disclosure and Authorization

PART I - DISCLOSER 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 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(s) 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 furnished USIS with information 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.

List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature.

By signing below, I certify that; (i) all information provided herein is complete and accurate; (ii) I have read and fully understand the Part I 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 purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of the authorization are a valid as an original

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, credit worthiness, credit capacity, bankruptcy fillings, 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 file 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. USIS may be contacted by mail at P.O. Box 33181, Tulsa, OK, 74153, or by phone at (800) 381-0645.

  • Check here if you are applying for employment in California and/or you are a California resident and, in either case, you wish to receive a copy of your credit report or investigative consumer report if one is obtained or assembled by USIS. Pursuant to the California Civil Code, you may view the file maintained on you by USIS during normal business hours. You may also obtain a copy of this file by submitting proper identification and paying applicable costs for such file, if required by law, by contacting USIS in person or by mail. USIS is required to have personnel available to explain your file to you and must explain to you any coded information appearing in you file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.
  • Check here if you are applying for employment in Oklahoma and/or you are an Oklahoma resident and, in either case, you wish to receive a copy of your consumer report if one is obtained or assembled by USIS.
  • Check here if you are applying for employment in Minnesota and/or you are a Minnesota resident and, in either case, you wish to receive a copy of your consumer report if one is obtained or assembled by USIS.

PART II - AUTHORIZATION FOR RELEASE ON INFORMATION (FOR EMPLOYMENT)

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 hires 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 the authorization are as valid as an original.

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

MANDATORY USE FOR ALL MONTHLY ACCOUNT HOLDERS

IMPORTANT NOTICE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

1. In connection with your application for employment with ("Prospective Employer"), it may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing.

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

2. I authorize ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

3. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

4. Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

NOTICE: This form is made available to monthly account holders by NICT on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain a driver's written or electronic consent prior to accessing the driver's PSP report. Further, account holders are required by FMCSA to use the language provided in paragraphs 1-4 of this document to obtain a prospective driver's consent. The language must be used in whole, exactly as provided. The language may be included with other consent forms or language at the discretion of the account holder, provided the four paragraphs remain intact and the language is unchanged.

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