LVT Driver Employment Application

DRIVER APPLICATION FORM Larry Vititow Trucking, LLC, P.O. Box 351, Sulphur Springs, TX 75483 Tel # 800-426-3631 Fax 903-885-5946 What type of job are you seeking? Check all that apply OTR Dedicated Local Part Time Personal Information
Last Name
First Name
Middle Name
Social Security	- -
Phone Number	( )
Alternate Phone Number	( )
E-mail Address
Date of Birth	Month Day Year
Present Address
Street
City
State
Zip
Permanent Address
Street
City
State
Zip
Have you lived at this address for more than 3 years?	Yes No
If no, list all residential addresses for the last 3 years. Include street address, city, state, and zip code.
Are you a United States citizen?	Yes No
If no, can you verify legal right to work in the United States?	Yes No
Date Available for work	Month Day Year
Criminal Record
Have you ever been charged with a crime? If no, go to next section.	Yes No
If yes, provide date/s.
If yes, what was the criminal charge?
Was the crime you were charged with a felony or misdemeanor?	Felony Misdemeanor
Have you ever been convicted of a crime?	Yes No
If yes, provide date/s.
If yes, what was the criminal charge for which you were convicted?
Was the crime you were charged with a felony or misdemeanor?	Felony Misdemeanor
Driver's License Information & Record Section 383.21 Federal Motor Carrier Safety Regulations 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.
Driver's License Number
State
Year of Expiration	yyyy Example: 2012
What type of driver are you?	Owner/Operator Experienced
Do you have a CDL?	Yes No
Do you have a Haz-Mat Endorsement?	Yes No
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?	Yes No
If yes, give details.
Has your license ever been suspended or revoked?	Yes No
If yes, list date/s
If yes, provide reason/s.
Have you been ticketed in the last 3 years?	Yes No
If yes, list all violations of motor vehicle laws for which you were convicted or forfeited bond or collateral during the past 3 years.
Have you had any accidents in the last 3 years?	Yes No
If yes, list dates, nature of each accident, and any fatalities or personal injuries caused.
What was the dollar amount of damage?
How many accidents were your fault?
Have you ever been arrested for driving under the influence?	Yes No
If yes, how many times?
If yes, provide date/s
Personal References - Do not list relatives
1. Name
Relationship
Telephone Number	( )
2. Name
Relationship
Telephone Number	( )
3. Name
Relationship
Telephone Number	( )
Employment History All applicants wishing to drive in interstate or intrastate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten years of employment record.) Any gaps in employment and/or unemployment must be explained. The Federal motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway to transport passengers or property when the vehicle: Interstate - (1) Vehicle 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 requiring placards. Intrastate - (1) Vehicle weighs or has a GVWR of 26,001 pounds or more, (2) is designed or used to transport 16 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placards.
Dates of Employment - From To Previous Employer - Name Telephone number( ) Address City State Zip Type of trailer Number of states Job title Reason for leaving Were you subject to the Federal Motor Carrier Safety Regulations while employed with this company? Yes No Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for periods between jobs - Include dates (month/year) and reason
Dates of Employment - From To Previous Employer - Name Telephone number( ) Address City State Zip Type of trailer Number of states Job title Reason for leaving Were you subject to the Federal Motor Carrier Safety Regulations while employed with this company? Yes No Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for periods between jobs - Include dates (month/year) and reason
Dates of Employment - From To Previous Employer - Name Telephone number( ) Address City State Zip Type of trailer Number of states Job title Reason for leaving Were you subject to the Federal Motor Carrier Safety Regulations while employed with this company? Yes No Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for periods between jobs - Include dates (month/year) and reason
Dates of Employment - From To Previous Employer - Name Telephone number( ) Address City State Zip Type of trailer Number of states Job title Reason for leaving Were you subject to the Federal Motor Carrier Safety Regulations while employed with this company? Yes No Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for periods between jobs - Include dates (month/year) and reason
Dates of Employment - From To Previous Employer - Name Telephone number( ) Address City State Zip Type of trailer Number of states Job title Reason for leaving Were you subject to the Federal Motor Carrier Safety Regulations while employed with this company? Yes No Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for periods between jobs - Include dates (month/year) and reason
Dates of Employment - From To Previous Employer - Name Telephone number( ) Address City State Zip Type of trailer Number of states Job title Reason for leaving Were you subject to the Federal Motor Carrier Safety Regulations while employed with this company? Yes No Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for periods between jobs - Include dates (month/year) and reason
Dates of Employment - From To Previous Employer - Name Telephone number( ) Address City State Zip Type of trailer Number of states Job title Reason for leaving Were you subject to the Federal Motor Carrier Safety Regulations while employed with this company? Yes No Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for periods between jobs - Include dates (month/year) and reason
Dates of Employment - From To Previous Employer - Name Telephone number( ) Address City State Zip Type of trailer Number of states Job title Reason for leaving Were you subject to the Federal Motor Carrier Safety Regulations while employed with this company? Yes No Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for periods between jobs - Include dates (month/year) and reason
Dates of Employment - From To Previous Employer - Name Telephone number( ) Address City State Zip Type of trailer Number of states Job title Reason for leaving Were you subject to the Federal Motor Carrier Safety Regulations while employed with this company? Yes No Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for periods between jobs - Include dates (month/year) and reason
Dates of Employment - From To Previous Employer - Name Telephone number( ) Address City State Zip Type of trailer Number of states Job title Reason for leaving Were you subject to the Federal Motor Carrier Safety Regulations while employed with this company? Yes No Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for periods between jobs - Include dates (month/year) and reason
Dates of Employment - From To Previous Employer - Name Telephone number( ) Address City State Zip Type of trailer Number of states Job title Reason for leaving Were you subject to the Federal Motor Carrier Safety Regulations while employed with this company? Yes No Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for periods between jobs - Include dates (month/year) and reason
ACKNOWLEDGEMENT, AGREEMENT & RELEASE
I give Larry Vititow Trucking (hereinafter called the Company) the right to investigate all references and to secure additional job related information about me. I release from liability the Company and its representatives for seeking information and all other persons, corporations, or organization for furnishing such information. A copy of this page serves as my authorization to seek and/or provide this information. I agree to sign all documents and consent forms which the Company deems necessary to verify the facts provided in this application. I give my consent, and release from liability the Company and its representatives, to respond to any inquiries made about me as part of a reference check by any subsequent or potential employer. I authorize release of any information, including all information related to my alcohol and controlled substance testing and training records conducted under The Federal Highway Administration (FHWA) 49 CFR Parts 391 or 382, by any past or current employers to Larry Vititow Trucking. I consent to the acquisition and use of any consumer reports, deemed necessary by the Company, in consideration of my employment. From time to time the Company may find it necessary to conduct investigations. If it does, employees are expected to truthfully participate and cooperate in such investigations, including submission to searches of property. Failure to do so may subject employees to disciplinary action, which may include termination of employment. I realize as a condition of employment I will be required to undergo a post offer and pre-employment medical examination and substance abuse screening testing as required by the Company, and that any offer of employment is conditioned upon the successful completion of the tests. I agree to furnish all required additional information and undergo any other examinations or tests to complete the employment file, or to continue my employment (if currently employed) with the Company. Tests may include, but are not necessarily limited to random, for cause, reasonable suspicion or post-accident alcohol and substance abuse screening tests. 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 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 the Immigration Reform & Control Act of 1986 (IACA). This application is active for sixty (60) days from the date it is completed, or until the specific position opening for which it was submitted is closed, whichever is earlier. Subsequent to the preceding consideration period. I must submit a new application to be considered for this or any other position. 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 I am already employed. Further, I understand that I am free to resign at any time, for any reason, with or without prior notice. I further agree that he Company reserves the right to terminate my employment at any time, for any reason, with or without prior notice. I understand that no representative of the Company has 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 or the intent of the parties and may not be modified except by a writing duty executed by the undersigned and an officer of the Company. I hereby agree to submit to binding arbitration all disputes and claims arising out of the submission of this or other formal application. I further agree, in the event that I am offered employment by the company, as a condition of that employment all disputes that cannot be resolved by informal internal resolution which might arise out of submission of this application or out of my employment with the company, whether before, during or after such employment will be submitted to binding arbitration in lieu of any Federal or State investigative, administrative, civil or other legal Proceeding. I agree to such arbitration shall be conducted in accordance with the Larry Vititow Dispute Resolution Program. A copy of The Program is available at Larry Vititow for review, upon request. I have read carefully the above information, understand and accept the contents. By submitting this application, I certify that all information on this form is correct and complete to the best of my knowledge. I understand that the information in this application will be used and that prior positions will be contacted for purposes of investigation required by 391.23 of the Motor Carrier Safety regulations. I hereby authorize release of any information on this application and release said persons, previous employers and Larry Vititow Trucking from any liability or damages. By entering your name and date in the boxes, below, you certify that the information in this application and all entries in it and information in it are true and complete to the best of your knowledge. Signature (Enter your name) Date Submitted Click only once