Application: DOT - StateLine Cooperative

Name *

First

Middle

Last

Date / Time *

Position(s) applied for or type of work desired:

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Address #2 (If above residence is less than three years, please list below all residences for the past three years.)

Address Line 1

Address Line 2

City

State

Zip Code

Address #3 (If applicable.)

Address Line 1

Address Line 2

City

State

Zip Code

Address #4 (If applicable.)

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Type of employment desired:

Full-Time
Part-Time
Temporary

Select all that apply.

Date you will be available to start work:

Are you able to meet the attendance requirements?

Yes
No

Do you have any objection to working overtime if necessary?

Yes
No

Have you ever been previously employed by our organization?

Yes
No

Can you submit proof of legal employment authorization and identity?

Yes
No

If you are under 18, can you furnish a work permit if it is required?

Yes
No

Have you had any injuries in the last year?

Yes
No

Do you have a valid Class A CDL driver's license?

Yes
No

How were you referred to us?

** Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, handicap or veteran status.

Educational History

List school name and location, years completed, course of study, and any degrees earned:

High School:

College:

Technical Training:

Other:

Employment History – 10 Year Minimum Required

Please provide all employment information for your past four employers starting with the most recent.

Upload Additional Document (If Desired)

Click or drag a file to this area to upload.

You may upload an additional resume or document if it lists previous employers.

Most Recent Employer

Employer

Position Held

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Immediate supervisor and title:

Time employed:

Dates From and To

Salary:

Job Summary:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations while employed?

Yes
No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to 49 CRF Part 40 alcohol/drug testing?

Yes
No

Previous Employer #2

Position Held

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Immediate supervisor and title:

Time employed:

Dates From and To

Salary:

Job Summary:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations while employed?

Yes
No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to 49 CRF Part 40 alcohol/drug testing?

Yes
No

Previous Employer #3

Position Held

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Immediate supervisor and title:

Time employed:

Dates From and To

Salary:

Job summary:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations while employed?

Yes
No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to 49 CRF Part 40 alcohol/drug testing?

Yes
No

Previous Employer #4

Position Held

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Immediate supervisor and title:

Time employed:

Dates From and To

Salary:

Job summary:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations while employed?

Yes
No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to 49 CRF Part 40 alcohol/drug testing?

Yes
No

Notes

The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more. (2) Is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity required placarding

Accident History (3 Years)

If no accidents within the last three years, skip to the next section.

Accident #1

Date of Accident

Nature of Accident

Number of Fatalities

Number of Injuries

Hax-Mat Spill?

Accident #2

Date of Accident

Nature of Accident

Number of Fatalities

Number of Injuries

Haz-Mat Spill?

Accident #3

Date of Accident

Nature of Accident

Number of Fatalities

Number of Injuries

Haz-Mat Spill?

Accident #4

Date of Accident

Nature of Accident

Number of Fatalities

Number of Injuries

Haz-Mat Spill?

Traffic Convictions (3 Years)

If no traffic convictions in last three years, skip this section.

Conviction #1

Date Convicted

Violation

State of Violation

Penalty (fine, jail, etc.)

Conviction #2

Date Convicted

Violation

State of Violation

Penalty (fine, jail, etc.)

Conviction #3

Date Convicted

Violation

State of Violation

Penalty (fine, jail, etc.)

License Information

Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license.” I certify that I do not have more than one motor vehicle license, the information for which is listed below.

State

License Number

Expiration Date

Applicant's Date of Birth

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

If yes, give details:

Driving Experience

If no driving experience within the last three years, skip this section.

Straight Truck

Type of Equipment (Select All That Apply)

Van
Reefer
Tank
Flat

Dates (From – To)

Approximate Number of Miles

Tractor and Semi-Trailer

Checkboxes

Van
Reefer
Tank
Flat

Dates (From – To)

Approximate Number of Miles

Tractor – Two Trailers

Checkboxes

Van
Reefer
Tank
Flat

Dates (From – To)

Approximate Number of Miles

Tractor – Three Trailers

Checkboxes

Van
Reefer
Tank
Flat

Dates (From – To)

Single Line Text

Approximate Number of Miles

Motor Coach – School Bus

Dates (From – To)

Approximate Number of Miles

Experience and Qualifications – Other

Show any trucking, transportation, or other experience that may help in your work for this company.

List courses and training other than shown elsewhere in this application.

Closing Authorization

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I understand that if I am employed, my driving record will be checked periodically by StateLine Cooperative and that if my driving record indicates serious violations or a frequency of violations; I may lose my driving assignment or be terminated. I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Applicant Signature

Date / Time