Employment Form - National Star Inc

PERSONAL INFORMATION – Step 1 of 15

Thank you for your interest in National Star Inc. To apply for a driving position, please complete our online application for employment. Incomplete information will delay the processing of your application or prevent it from being submitted.

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

PERSONAL INFORMATION

Name *

First

Middle

Last

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

SSN/SIN *

Date of Birth *

Primary Phone *

Cell Phone *

Email *

In case of Emergency, notify (list name, address, and phone):

Alternative Contact (Name and Phone)

Desired Start Date

LICENSE

Do you hold only one active/valid CDL? *

How long have you been issued your current CDL? *

Is your CDL currently or recently suspended or cancelled? *

Please explain:

LICENSE RESTRICTIONS

Check the box if is compliant with your license *

Automatic Transmission Only / Non-Manual
Daylight Only Operation
CDL Intrastate Only
No Air Brakes
I don’t have any restriction on my driving license

Other restrictions

LICENSES

Enter all drivers licenses that have been active within the last 5 years

Current License number *

State/Province *

Country *

License Class *

License Expiration *

Physical Expiration Date *

Commercial Driver

Other drivers licenses (License number, State/Province, Country, License Class, License Expiration, Physical Expiration Date) *

Endorsements

Tanker Endorsement

HAZMAT Endorsement

X Endorsement

Doubles Triples Endorsement

Other Endorsement

COMPANY QUESTIONS

What position are you applying for?

Company Driver
Lease to Purchase
Owner Operator

Other position ( enter the name on the position you apply )

How did you hear about us? *

If "Driver Referral", please enter the driver's name *

If "Other", please explain

EQUIPMENT (OWNER OPERATORS ONLY)

Equipment Description (Tractor):

Year, Make, Model:

VIN:

Truck Owner's Name and Phone Number

Are you legally eligible for employment in the USA?

Are you currently employed?

Have you ever worked for this company before?

Do you have a current TWIC card? If Yes, expiration:

Please enter the names of any relatives employed here:

Have you ever been known by any other name?

TRUCKING SCHOOL

Start Date – End Date

School

Address

Phone

Were you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while attending this truck school?

Did you perform any safety sensitive functions at this truck school, regulated by DOT, and subject to drug and alcohol testing?

GPA; Hours of Instruction;

Federal Motor Carrier Regulations; Log Books;

Hazardous Materials

Section Divider

TRUCKING EMPLOYMENT / UNEMPLOYMENT VERIFICATION

The U.S. Department of Transportation requires that driver applicants provide all transportation employment for the past 5 years.

PLEASE ACCOUNT FOR ALL TIME PERIODS IN THE PAST 5 YEARS. LEAVE NO GAPS.

UNEMPLOYMENT 1

Start Date – End Date

Comment

UNEMPLOYMENT 2

Start Date – End Date

Comment

UNEMPLOYMENT 3

Start Date – End Date

Comment

TRUCKING HISTORY EMPLOYMENT

The U.S. Department of Transportation requires that driver applicants provide all transportation employment for the past 5 years.

PLEASE ACCOUNT FOR ALL TIME PERIODS IN THE PAST 5 YEARS. LEAVE NO GAPS.

EMPLOYMENT 1

Company 1 *

Start Date *

End Date *

Address *

Phone *

Position Held *

Reason for leaving?

Were you terminated/discharged/laid off?

May we contact this employer at this time?

Were you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while employed/contracted by this employer/contractor?

Areas Driven

Miles driven weekly

Most common truck driven

Trailer length

Pay Range (cents/mile)

TRUCKING EMPLOYMENT HISTORY 2

The U.S. Department of Transportation requires that driver applicants provide all transportation employment for the past 5 years.

Company 2

Start Date

End Date

Address

Phone

Position Held

Reason for leaving?

Were you terminated/discharged/laid off?

May we contact this employer at this time?

Were you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while employed/contracted by this employer/contractor?

Areas Driven

Miles driven weekly

Most common truck driven

Trailer length

Pay Range (cents/mile)

TRUCKING EMPLOYMENT HISTORY 3

The U.S. Department of Transportation requires that driver applicants provide all transportation employment for the past 5 years.

Company

Start Date – End Date

Address

Phone

Position Held

Reason for leaving?

Were you terminated/discharged/laid off?

May we contact this employer at this time?

Areas Driven

Miles driven weekly

Most common truck driven

Trailer length

Pay Range (cents/mile)

TRUCKING EMPLOYMENT HISTORY 4

The U.S. Department of Transportation requires that driver applicants provide all transportation employment for the past 5 years.

Were you subject to the Federal Motor Carrier or Transport Canada Safety Regulations while employed/contracted by this employer/contractor?

Company

Start Date – End Date

Address

Phone

Position Held

Reason for leaving?

TRUCKING EMPLOYMENT HISTORY 5

The U.S. Department of Transportation requires that driver applicants provide all transportation employment for the past 5 years.

Company

Start Date – End Date

Address

Phone

Position Held

Reason for leaving?

TRUCKING EMPLOYMENT HISTORY 6

The U.S. Department of Transportation requires that driver applicants provide all transportation employment for the past 5 years.

Company

Start Date – End Date

Address

Phone

Position Held

Reason for leaving?

FMCSR

Under FMCSR 391.15, are you currently disqualified from driving a commercial motor vehicle? [49 CFR 391.15] *

Has your license, permit or privilege to drive ever been suspended or revoked for any reason? [49 CFR 391.21(b)(9)] *

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?[49 CFR 391.21(b)(9)] *

Have you ever tested positive, or refused to test, on a pre- employment drug or alcohol test by an employer to whom you applied, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules? [49 CFR 40.25(j)] *

Have you ever been convicted of any of the following offenses: [49 CFR 391.15]: Driving a commercial motor vehicle with a blood alcohol concentration ("BAC") of .04 percent or more Driving under the influence of alcohol, as prescribed by state law Refusal to undergo drug and alcohol testing as required by any jurisdiction for the enforcement of Federal Motor Carrier Safety Act regulations Driving a commercial motor vehicle under the influence of any 21 C.F.R. 1308.11 Schedule I identified controlled substance, an amphetamine, a narcotic drug, a formulation of an amphetamine, or a derivative of a narcotic drug Transportation, possession, or unlawful use of a 21 C.F.R. 1308.11 Schedule I identified controlled substance, amphetamines, narcotic drugs, formulations of an amphetamine, or derivatives of narcotic drugs while you were on duty driving for a motor carrier Leaving the scene of an accident while operating a commercial motor vehicle Or any other felony involving the use of a commercial motor vehicle *

VEHICLE ACCIDENT RECORD

Were you involved in any accidents/incidents with any vehicle in the last 5 years (even if not at fault)? *

TRAFFIC CONVICTIONS / VIOLATIONS

Have you had any moving violations or traffic convictions in the past 3 years? *

FCRA AUTHORIZATION

By checking YES, I (a) acknowledge that I have and understand the above and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally as an ink signature. *

EMPLOYMENT VERIFICATION ACKNOWLEDGEMENT AND RELEASE (DOT DRUG AND ALCOHOL)

By checking YES, I (a) acknowledge that I have read and understand the above and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. *

CLEARINGHOUSE RELEASE

By checking the box, I (a) acknowledge that I have read and understand the above and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. *

AUTHORIZATION TO OBTAIN MOTOR VEHICLE RECORD

By checking this box, I represent that I understand and agree to the above authorization to Obtain Motor Vehicle Record. *

SUMMARY OF RIGHTS UNDER 15 U.S.C. SECTION 1681 m(a)

By checking the box, I (a) acknowledge that I have read and understand the Summary of rights Under 15 U.S.C. Section 1681m(a) and have been given the opportunity to copy/print the 1681m Summary of Rights and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. *

SIGNATURE

Signature *

Clear Signature

Date *