Folkens Brothers Trucking

Since 1979

800-831-8553

Jonathan (Trim) Folkens

PO Box 62

Lester, Iowa  51242

                U.S.A.

DRIVER APPLICATION FORM

COMPANY NAME

COMPANY ADDRESS

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, 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 the Company.

 

"I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating 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 current/previous employees;
  • Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
  • Have a rebuttal statement attached to lie alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information."

NAME

ADDRESS

PAST 3 YEAR 

RESIDENCY

Employment History

(Use Additional Employment History Information form if necessary)

All applicants wishing to drive in interstate 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 year employment record).

You are required to list the complete mailing address: street number and name, city, state, and zip code.

CURRENT OR LAST EMPLOYER

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

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?

SECOND LAST EMPLOYER

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

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?

THIRD LAST EMPLOYER

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

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?

EXPERIENCE AND QUALIFICATION

 

Attach separate sheet if more space is needed

 

Drivinq Experience

CLASS OF EQUIPMENT

TYPE OF EQUIPMENT

(Choose all that apply)

DATES

FROM

TO

APPROXIMATE

NUMBER OF MILES

Accident History (3 years)

DATE

(month/year)

NATURE OF ACCIDENT

(head-on, rear-end, upset, etc.)

NUMBER OF FATALITIES

NUMBER OF INJURIES

HUZURDOUS MATERIALS SPILL?

Traffic Convictions and Forfeitures (3 years)

DATE CONVICTED

(month/year)

VIOLATION

(Other than violations involving parking only)

STATE OF VIOLATION

PENALTY

(Forfeited bond, collateral and/or points)

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.

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

If yes, give details

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

If yes, give details

Applicant Certification

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