"Nobody Pays Faster Than Scott's"            

 

                                                

             

Home
Up

      

 

Application for Qualification

 

Company       

 Address              City   

State             Zip Code  

The purpose of this application is to determine whether or not the applicant is qualified to operate Motor Carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company named above.

INSTRUCTIONS TO APPLICANT

Please answer all questions.  If the answer to any question is "No" or "None", do not eave the item blank, but write "No" or "None".  This is important!

The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

 

Date (mm-dd-yy)       Contractor     Driver

Name (First, Middle, Last) 

Date of Birth            Age 

Social Security #         

Phone Number          Email

 

Current & 3 Years Previous Addresses: 

Street            City           

State/Zip  

From: (mm-dd-yy)           To: (mm-dd-yy)   

Current & 3 Years Previous Address: 

Street            City           

State/Zip  

From: (mm-dd-yy)           To: (mm-dd-yy)   

Current & 3 Years Previous Address: 

Street            City           

State/Zip  

From: (mm-dd-yy)           To: (mm-dd-yy)   

Current & 3 Years Previous Address: 

Street            City           

State/Zip  

From: (mm-dd-yy)           To: (mm-dd-yy)   

Current & 3 Years Previous Addresses: 

Street            City           

State/Zip  

From: (mm-dd-yy)           To: (mm-dd-yy)   

Education and Employment History

Highest grade completed   

Give a COMPLETE RECORD of all employment for the past 3 years, including any unemployment or self employment, and all commercial driving experience for the past ten years.

PRESENT OR LAST EMPLOYER:

Name   

From (Mo/Yr)                        To (Mo/Yr)              

Address (Street)             (City)         

(State/Zip)   

Position Held           Salary       

Reason For Leaving     

NEXT PREVIOUS EMPLOYER:

Name   

From (Mo/Yr)                        To (Mo/Yr)              

Address (Street)             (City)         

(State/Zip)   

Position Held           Salary       

Reason For Leaving     

NEXT PREVIOUS EMPLOYER:

Name   

From (Mo/Yr)                        To (Mo/Yr)              

Address (Street)             (City)         

(State/Zip)   

Position Held           Salary       

Reason For Leaving     

NEXT PREVIOUS EMPLOYER:

Name   

From (Mo/Yr)                        To (Mo/Yr)              

Address (Street)             (City)         

(State/Zip)   

Position Held           Salary       

Reason For Leaving     

NEXT PREVIOUS EMPLOYER:

Name   

From (Mo/Yr)                        To (Mo/Yr)              

Address (Street)             (City)         

(State/Zip)   

Position Held           Salary       

Reason For Leaving     

DRIVING EXPERIENCE

CLASS OF EQUIPMENT

DATES

      FROM                TO

APPROX. NO. OF MILES

(TOTAL)

 
STRAIGHT TRUCK
TRACTOR AND SEMI-TRAILER
TRACTOR-TWO TRAILERS
OTHER

 

List states operated in for the last five years: 

 

Show special courses or training that will help you as a driver: 

 

What Safe Driving Awards do you hold and from whom?

 

ACCIDENT RECORD FOR PAST 3 YEARS

DATES

 

NATURE OF ACCIDENT

(HEAD-ON, REAR-END, UPSET, ETC.)

Location of

Accident

 # of

Fatalities

 # OF INJURED PEOPLE

 

TRAFFIC CONVICTIONS AND FORFEITURES
FOR THE LAST 3 YEARS
(other than parking violations)
LOCATION DATE CHARGE PENALTY


 

DRIVER'S LICENSES

(List each driver's license held in the past 3 years)

STATE LICENSE# TYPE ENDORSEMENTS EXPIRATION DATE


 

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

  YES   NO

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

YES   NO

If the answer to A or B is YES, give details:

 

PERSONAL REFERENCES

List three persons for reference, other than relatives, who have knowlege of your safety habits.

Name   

Address (Street)                  Address (City)         

Address (State/Zip)           Phone#           

Name   

Address (Street)                  Address (City)         

Address (State/Zip)           Phone#           

Name   

Address (Street)                  Address (City)         

Address (State/Zip)           Phone#           

 

TO BE READ AND AGREED TO BY APPLICANT

It is agreed and understood that any misrepresentation given above shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his/her furnishing such information.
 
It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.
 
I agree to furnish such additional information and complete such examinations as my be required to complete my employment file.
 
It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ the applicant.
 
It is agreed and understood that if qualified, the driver may be on a probationary period during which time he may be disqualified without recourse.
 
It is agreed and understood that you, if applying as a Owner/Operator driver, won't be directly employed by Scott's Express.  You will be employed by the truck owner and he/she will pay your wages.
 
This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

               

 

Remarks . . .

                  

 

 

 

Send mail to webmaster@scottsexpress.com with questions or comments about this web site.
Copyright ©  2007 Scott's Express and Transportation Services.