Application for Employment


I am applying for one of the following driving positions: 
Full-Time
Part-Time
Other
Truck Driving Experience:
Years
Apprentice Training Program
Truck Driver School Training
Social Security: 
(You may enter dates manually or use the Date Picker)
Date of Birth: 
First Name: 
Middle Initial: 
Last Name: 
Address: 
City: 
State: 
Zip: 
Telephone: 
Cell Phone: 
Email Address: 
Have you ever been known by any other name?
Yes
No
Other name:
If employed, can you provide verification
of your legal right to work in the United States?: 
Yes   
No   
Can you legally travel between the U.S. and Canada?: 
Yes   
No   
If No, please explain: 
Who referred you to our Company?: 
How did you hear about us?: 
The conviction of a crime is not an automatic bar to employment. All circumstances will be considered including the nature of the offense and the relationship of the offense to this Company's business. Failure to disclose all convictions will result in immediate disqualification.
Answer the following Yes or No.
If Yes, provide dates and explain in details column Date(s) / Details
Have you ever been convicted of a felony,
received a deferred prosecution,
or have any felony charges currently pending?: 
Yes   
No   
Conviction Date: 
Conviction Details: 
Have you ever been convicted of a misdemeanor,
received a deferred prosecution, or have any misdemeanors currently pending?: 
Yes   
No   
Conviction Date: 
Conviction Details: 
Have you ever been convicted of operating
a motor vehicle while under the influence
of alcohol or a controlled substance, or are any charges pending,
including reduction to a lesser charge? (List all dates): 
Yes   
No   
Conviction Date: 
Conviction Details: 
Have you ever been convicted of possession, sale, transfer or use of alcohol
or a narcotic drug, amphetamine,
inhalant, or derivative thereof, or have a current charge pending? (List all dates): 
Yes   
No   
Conviction Date: 
Conviction Details: 
Have you ever tested positive for
drugs/controlled substance or alcohol, or refused to submit to a required drug/alcohol test?: 
Yes   
No   
Conviction Date: 
Conviction Details: 
Have you ever been denied a license, permit or privilege
to operate a motor vehicle?: 
Yes   
No   
Conviction Date: 
Conviction Details: 
Has any driver's license, permit or privilege
ever been suspended or revoked?: 
Yes   
No   
Conviction Date: 
Conviction Details: 
Have you ever had a citation for leaving the scene of an accident?: 
Yes   
No   
Conviction Date: 
Conviction Details: 
List Additional Addresses in Last 3 Years:
StreetCityStateTime Period
From: To:
From: To:
Licenses: (List all driver license numbers assigned to you in the past 10 years.)
StateLicense NumberPersonalCommericalHazmat Yes?Hazmat No?Expires
Moving Violations: List all tickets and forfeitures for the past 5 years. Be sure to list all careless or reckless driving convictions or pending reckless or careless driving citations as such. (IF NONE, WRITE NONE)
Moving Violation Occurences:
DateConviction/Type(if speed, list mph over limit)City/StateOther Details
Accidents: List all accidents you have been involved in within the last 5 years regardless of fault, severity, or motor vehicle type. (IF NONE, WRITE NONE) (Please use additional sheet of paper for complete accident description if necessary.)Please describe the type of accident in detail.
Accident Occurences:
Date Accident Type City/State Preventable/Non-Preventable #Fatalities # Injuries
If ever involved in a fatality accident, please explain:
Education:
Circle highest grade completed:1
2
3
4
5
6
7
8

High School:9
10
11
12

College:1 year
2 years
3 years
4 years
CDL Driving School Name: 
City : 
State : 
Phone : 
Fax : 
Email : 
Course Length (Weeks): 
CDL Graduation Date: 
Employment History: Starting with your most recent employer, provide 10 years of work history for driving jobs, 5 years of work history for non-driving jobs. Please include all phone numbers. Account for all time, including military service, periods of self-employment, and unemployment for more than 2 weeks. Provide documentation for periods of self-employment and military that includes affidavits, tax records, or DD214 long form for the last 5 years.
Have you ever worked for this Company before?
Yes
No
If yes, when: Position:
Have you ever been unemployed?
Yes
No
Employment History Occurences:
Please select a number from the drop-down box above that would correspond to the total number of jobs you have had in the last 3-5 years.
  Period of Non-Employment: From To Reason
Current or Last Employer:
Employed From:
To:
Full Time:
Part Time:
Miles Driven Weekly:
Company Name:
Phone:
Address:
City:
State:
Position Held:
Truck Type:
Pay Rate:
Were you subject to the FMCSR's:
Yes
No
Was your job designated as a safety-sensitive function
in any DOT regulated mode subject to the Drug & Alcohol
testing requirements of 49 CFR Part 40?
Yes
No
Reason for leaving:
May we contact this employer?
Yes
No
  Period of Non-Employment: From To Reason
Prior Employer:
Employed From:
To:
Full Time:
Part Time:
Miles Driven Weekly:
Company Name:
Phone:
Address:
City:
State:
Position Held:
Truck Type:
Pay Rate:
Were you subject to the FMCSR's:
Yes
No
Was your job designated as a safety-sensitive function
in any DOT regulated mode subject to the Drug & Alcohol
testing requirements of 49 CFR Part 40?
Yes
No
Reason for leaving:
May we contact this employer?
Yes
No
  Period of Non-Employment: From To Reason
Prior Employer:
Employed From:
To:
Full Time:
Part Time:
Miles Driven Weekly:
Company Name:
Phone:
Address:
City:
State:
Position Held:
Truck Type:
Pay Rate:
Were you subject to the FMCSR's:
Yes
No
Was your job designated as a safety-sensitive function
in any DOT regulated mode subject to the Drug & Alcohol
testing requirements of 49 CFR Part 40?
Yes
No
Reason for leaving:
May we contact this employer?
Yes
No
  Period of Non-Employment: From To Reason
Prior Employer:
Employed From:
To:
Full Time:
Part Time:
Miles Driven Weekly:
Company Name:
Phone:
Address:
City:
State:
Position Held:
Truck Type:
Pay Rate:
Were you subject to the FMCSR's:
Yes
No
Was your job designated as a safety-sensitive function
in any DOT regulated mode subject to the Drug & Alcohol
testing requirements of 49 CFR Part 40?
Yes
No
Reason for leaving:
May we contact this employer?
Yes
No
  Period of Non-Employment: From To Reason
Prior Employer:
Employed From:
To:
Full Time:
Part Time:
Miles Driven Weekly:
Company Name:
Phone:
Address:
City:
State:
Position Held:
Truck Type:
Pay Rate:
Were you subject to the FMCSR's:
Yes
No
Was your job designated as a safety-sensitive function
in any DOT regulated mode subject to the Drug & Alcohol
testing requirements of 49 CFR Part 40?
Yes
No
Reason for leaving:
May we contact this employer?
Yes
No
  Period of Non-Employment: From To Reason
Prior Employer:
Employed From:
To:
Full Time:
Part Time:
Miles Driven Weekly:
Company Name:
Phone:
Address:
City:
State:
Position Held:
Truck Type:
Pay Rate:
Were you subject to the FMCSR's:
Yes
No
Was your job designated as a safety-sensitive function
in any DOT regulated mode subject to the Drug & Alcohol
testing requirements of 49 CFR Part 40?
Yes
No
Reason for leaving:
May we contact this employer?
Yes
No
  Period of Non-Employment: From To Reason
Prior Employer:
Employed From:
To:
Full Time:
Part Time:
Miles Driven Weekly:
Company Name:
Phone:
Address:
City:
State:
Position Held:
Truck Type:
Pay Rate:
Were you subject to the FMCSR's:
Yes
No
Was your job designated as a safety-sensitive function
in any DOT regulated mode subject to the Drug & Alcohol
testing requirements of 49 CFR Part 40?
Yes
No
Reason for leaving:
May we contact this employer?
Yes
No
APPLICANT AGREEMENT

To be carefully read and signed by applicant. If you have any questions or require an explanation of the terms of this Agreement, please ask for clarification.

I hereby authorize any law enforcement agency, court of record, or any third party agency to furnish J.A.T. of Ft. Wayne (the "Carrier") with information concerning my Motor Vehicle Record, or any felony or misdemeanor of which I have been convicted.

I understand and agree that the Carrier may procure my past employment records and background/credit information from a consumer credit bureau, as the Carrier deems necessary for the consideration of my employment.

I understand that this application for employment will not be accepted as final until satisfactorily completing a medical examination including drug testing, as well as a driving skill exam and personal interview. The location of these exams and requirements shall be at the sole discretion of the Carrier. I further agree to provide access to previous medical records if required.

I understand my application may be transferred to an electronic filing system, and the original may not be retained.

I acknowledge and agree that, as a condition of employment with the Carrier, I will be subject to the alcohol and controlled substances regulations as published in the Federal Motor Carrier Safety Regulations (FMCSR), parts 40 and 382. I further agree to submit urine and breath samples as necessary to comply with the testing requirements of the regulations. I understand that a positive test result for controlled substances (including adulterated samples or refusals to test) or test results indicating a Blood Alcohol Content (BAC) of .04 or greater will be grounds for refusal to hire or immediate termination of my employment, if hired.

I understand that at any point in the future, whether I am actively employed by the Carrier or not, the Carrier may provide information concerning my employment and services with the Carrier to any party that requests such information. I agree that said information may be furnished on my behalf without any liability or damages to the Carrier.

I understand and agree that my submitting this application to the Carrier for employment in no way obligates the Carrier to offer me employment.

I understand that if I am hired, my employment will be "at will", meaning for no definite period, regardless of the period of payment of my wages. I further understand that I have the right to terminate my employment at any time with or without notice, and the Carrier has the same right. I understand that no supervisor, manager, or executive of the Carrier, other than the President, has the authority to alter the foregoing and the President may do so only in writing that is signed by both the President and the employee in question.

I hereby authorize, without liability, any person or organization whose name I have given as reference, or by whom I have been previously employed or contracted with, to furnish to J.A.T. of Ft. Wayne any information they may have concerning my character, habits, ability, financial responsibility, job performance, reasons for leaving employment/lease, and all information concerning my employment/lease. I hereby release all such persons and organizations from any claims for damages of any kind, which may occur to me by reasons of furnishing such 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. Any false, misleading or incomplete statement of the information requested in this application and any supplemental material submitted shall be sufficient grounds for disqualification of this application or termination from employment, if this application results in employment.

I have read and understand the terms of the above Agreement.

Applicant's Printed Name: 
(Check this box to confirm your digital signature)
PAST EMPLOYMENT INFORMATION REQUEST FORM AUTHORIZATION
DRUG/ALCOHOL TESTING HISTORY INQUIRY AUTHORIZATION
IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE AUTHORIZATION
In connection with your application for employment with JAT of Fort Wayne ("Prospective Employer"), Prospective Employer, its employees, agents or contractors 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.

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. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

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 Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.


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

I authorize JAT of Fort Wayne ("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 authorizing 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.

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 challenge 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.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.

I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, 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.