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(574) 212-0100
dispatch@sultantrans.com
2989 SYMMES RD FAIRFIELD, OH 45014
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Step
1
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Personal Information
First
*
Middle
Last
*
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Zip
*
Previous Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Previous Address 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Phone
*
Email
*
SS#
*
DOB
*
CDL#
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Exp
*
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
*
Yes
No
Has any license, permit or privilege ever been suspended or revoked?
*
Yes
No
Tickets / Accidents - Past 3 Years
Date
Description
# Injuries
Date
Description
# Injuries
Traffic Convictions & Forfeitures for Past 3 Years
Date
Charge
Location
Date
Charge
Location
Date
Charge
Location
Emergency Contact
Name
Phone
Next
Work History
Employer 1
Employer
*
Employed From
*
To
*
Address
*
Phone
*
Supervisor
*
Position
*
Reason For Leaving
Were you subject to the FMCSRs while employed?
*
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
Employer 2
Employer
Employed From
To
Address
Phone
Supervisor
Position
Reason For Leaving
Were you subject to the FMCSRs while employed?
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
Employer 3
Employer
Employed From
To
Address
Phone
Supervisor
Position
Reason For Leaving
Were you subject to the FMCSRs while employed?
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
Employer 4
Employer
Employed From
To
Address
Phone
Supervisor
Position
Reason For Leaving
Were you subject to the FMCSRs while employed?
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
Employer 5
Employer
Employed From
To
Address
Phone
Supervisor
Position
Reason For Leaving
Were you subject to the FMCSRs while employed?
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
Employer 6
Employer
Employed From
To
Address
Phone
Supervisor
Position
Reason For Leaving
Were you subject to the FMCSRs while employed?
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
Previous
Next
Fair Credit Reporting Act Disclosure Statement
In accordance with the provisions of Section 604 (b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. Your employer may obtain this information from Equifax, Transunion, Experian or other vendors of information services.
Name
*
Date
*
SS#
*
Employer Witness
Company Name
Alcohol and Controlled Substance Consent and Release
In accordance with the provisions of Section 604 (b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. Your employer may obtain this information from Equifax, Transunion, Experian or other vendors of information services.
Have you ever refused to be tested for drugs & alcohol at any time in the last 2 years?
*
Yes
No
Have you ever tested positive for drugs or alcohol at any time in the last 2 years?
*
Yes
No
Have you ever tested positive on any pre-employment drug or alcohol test for a job which you applied for but did not obtain?
*
Yes
No
If you answered yes to any of the above questions, you will be asked to submit a statement of explanation and provide proof of return to duty process.
I understand that, as required by the Federal Motor Carrier Safety Regulations and company policy, all drivers must submit to alcohol and controlled substance testing as a condition of employment. I also understand that any offer of employment will be contingent upon the results of an alcohol and controlled substance test.
Therefore, I agree to submit to the following alcohol and controlled substance tests in accordance and as defined by the Federal Motor Carrier Safety Regulation and this company’s policies:
Pre-Employment, to determine employment eligibility
Random
Reasonable Suspicion
Post-Accident
I certify that I have read, understand, and agree to abide by the condition of this consent and release form.
Name
*
Date
*
SS#
*
Employer Witness
Company Name
Previous
Next
Driver's Authorization to Obtain Past Drug and Alcohol Test Results
I understand that as a condition of qualification, I must give the Company written authorization to obtain the resultS of all DOT required drug and/or alcohol test (including any refused to be tested) from all of the companies for which I worked as a driver, or for which I took a pre-employment drug and/or alcohol test, during the past two (2) years. I have also been advised and understand that my signing of this authorization does not guarantee me a job or guarantee that I will be qualified with the Company.
Below I have listed all of the companies for which I worked as a driver, or to which applied as a driver during the past two (2) years. I hereby authorize the Company to obtain from those companies, and I hereby authorize those companies to furnish to Company, the following information concerning my drug and alcohol test: (I)all positive drug test results during the past two (2) years; (II) all alcohol test results of 0.04 or greater during the past two (2) years; (III) all alcohol test results of 0.02 or greater but less than 0.04 during the past two (2) years;(IV) all instances in which I refused to submit to a DOT required drug and/or alcohol test during the past two (2) years.
The following is a list of all of the companies which I worked as a driver, or to which I applied for work as a driver, during the past two (2) years:
Company Name
Start Date
End Date
Company Name
Start Date
End Date
Company Name
Start Date
End Date
Company Name
Start Date
End Date
Company Name
Start Date
End Date
Drivers Certification
I have carefully read and fully understand this authorization to release my past drug and alcohol test results. In signing below, I certify that all of the information which I have furnished on this form is true and complete, and that I have identified all of the companies for which I have either worked, or applied for work, as a driver during the past two years.
Name
*
Date
*
Previous
Next
Motor Vehicle Driver's Certification of Compliance With Driver License Requirements
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate. Interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or hazardous materials that require place carding.
The requires in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transport hazardous materials that require place carding.
DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. There requirements are in effect as of July 1st 1987 . They are as follows:
You as a commercial vehicle driver, may not possess more than one license. The only exception is if a state requires you to have more than one license. This exception is allowed until January 1, 1990. If you currently have more than one license, you should keep the license from your state of residence and return the additional license to the states that issued them. DESTROYING a license does not close the records in the state that issued it; you must notify the state. If a multiple has been lost, stolen or destroyed, you should close your record by notifying the state of issuance that you no longer want to be licensed in that state.
Part 392.42 and Part 383.33 of the Federal Motor Carrier Safety Regulations required that you notify you employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Part 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it to your employing motor carrier and the state that issued your license within 30 days.
DRIVER CERTIFICATION: I certify that I have read and understand the above requirements. The following license is the only one I will possess:
Driver's Name
*
Driver's License Number
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Exp
*
Previous
Next
Hours of Service Record
Name
SS#
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
I hereby certify that the information contained hereon is true to the best of my knowledge and belief, and that my last period of release from duty was:
From
To
Seatbelt Usage Policy
We value the lives and safety of our employees and contractors. Seatbelts are proven to greatly reduce the risk of dying or being seriously injured in a motor vehicle crash. Of course, seatbelt usage is also a federal requirement for commercial drivers under FMCSR 392.16. Because of our commitment to employee safety and compliance with the law, our company has adopted the following policy regarding employee seatbelt usage.
All employees are required to use a seatbelt when traveling in any vehicle while in the course of conducting company business. This policy applies to employees, independent contractor truck drivers, and those who operate other company vehicles.
Failure to abide by this stated policy will be considered a violation of our company policy and will subject the person who is in violation to disciplinary action, which could include suspension and possible termination of employment or termination of lease.
Name
*
Date
*
Previous
Next
Safety Performance History Records Request
Please read the statement(s) below. By selecting "I agree" under the statement(s), you are giving us permission to request safety performance records from that employer.
I,
Hereby authorize
phone:
address:
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substance Testing records within the previous 3 years from
to
I have read and agree to the above records request
Yes, I agree
I,
Hereby authorize
phone:
address:
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substance Testing records within the previous 3 years from
to
I have read and agree to the above records request
Yes, I agree
I,
Hereby authorize
phone:
address:
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substance Testing records within the previous 3 years from
to
I have read and agree to the above records request
Yes, I agree
I,
Hereby authorize
phone:
address:
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substance Testing records within the previous 3 years from
to
I have read and agree to the above records request
Yes, I agree
I,
Hereby authorize
phone:
address:
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substance Testing records within the previous 3 years from
to
I have read and agree to the above records request
Yes, I agree
I,
Hereby authorize
phone:
address:
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substance Testing records within the previous 3 years from
to
I have read and agree to the above records request
Yes, I agree
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