+ (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