+ (206)-939-9030 dispatch@alphaintermodal.com

Employment

Employment Application Form

Company Name
Location: Region/District/Branch
Company Address
City
State
Zip Code

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 employers;
  • 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 the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.”
Signature
Date
NAME
Last
First
Middle
Social Security Number
Phone Number
Date of Birth
Hire Date
ADDRESS
Street
City
State
Zip
Number of Years
PAST 3 YEAR RESIDENCY
Street
City
State
Zip
Number of Years
Street
City
State
Zip
Number of Years

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
Name
Phone Number
Street Address
City
State
Zip
Position Held
From (month/year)
To (month/year)
Reasons for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed?
YesNo
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?
YesNo
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

SECOND LAST EMPLOYER
Name
Phone Number
Street Address
City
State
Zip
Position Held
From (month/year)
To (month/year)
Reasons for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed?
YesNo
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?
YesNo
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

THIRD LAST EMPLOYER
Name
Phone Number
Street Address
City
State
Zip
Position Held
From (month/year)
To (month/year)
Reasons for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed?
YesNo
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?
YesNo
*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

*Any gaps in employment and/or unemployment must be explained.

**The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport
passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than
8 passengers (including the driver) for compensation; or (3) is designed or used to transport more than 15 passengers, including the driver,
and is not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity
requiring placarding.

EXPERIENCE AND QUALIFICATION

Attach separate sheet if more space is needed
Driving Experience
If no driving experience within the last 3 years – check here
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT

(Circle all that apply)
DATES

FROM
To
 
APPROXIMATE NUMBER OF MILES
Straight Truck
Van, Reefer, Tank, Flat
Or
Tractor & Semi-Trailer
Van, Reefer, Tank, Flat
Or
Tractor – Two Trailers
Van, Reefer, Tank, Flat
Or
Tractor – Three Trailers
Van, Reefer, Tank, Flat
Or
Motorcoach – School Bus (Greater than 8 passengers)
N/A
Or
Motorcoach – School Bus (Greater than 15 passengers)
N/A
Or
Other
Van, Reefer, Tank, Flat, N/A
Or
Traffic Convictions and Forfeitures (3 years)
If no traffic convictions and/or forfeitures in the last 3 years – check here
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.

State
License Number
Expiration Date
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? YesNo
If yes, give details
B. Has any license, permit, or privilege ever been suspended or YesNo
If yes, give details
Applicant Certification
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.

Applicant’s
Date