Careers – Sanuka Motor Group

Driver Application

DATE OF BIRTH:

HIRE DATE:

PREVIOUS THREE YEARS RESIDENCY

LICENCE 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.

EXPIRATION DATE

DRIVING EXPERIENCE

CLASS OF EQUIPMENT

EQUIPMENT TYPE (VAN, TANK, FLAT, ETC.:

FROM:

TO:

APPROX NO. OF MILES:

STRAIGHT TRUCK

FROM:

TO:

TRACTOR AND SEMI TRAILER

FROM:

TO:

TRACTOR AND SEMI TRAILER

FROM:

TO:

OTHER

FROM:

TO:

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE

DATE:

CHEMICAL SPILLSYESNO

DATE:

CHEMICAL SPILLSYESNO

DATE:

CHEMICAL SPILLSYESNO

TRAFFIC CONVICTIONS and forfeitures for the past 3 years (other than parking violations)

DATE CONVICTED:

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

B. Has any license, permit or privilege ever bee suspended or revoked?If yes explain:

Employment Record

Applicants that desire to drive in intrastate/Interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle tor the seven years prior to the, initial three years (total of ten years employment record).
Must list the complete mailing address: street number and name, city, state and zip code.

LAST EMPLOYER

FROM:

TO:

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES (MONTH/YEAR) AND REASON

Were you subject to the Federal Motor Carner Safety Regulations (FMCSRs) while employed by the previous employer?YesNo

Was the previous job position designated as a safety sensitive function in any DOT regulated mode. subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?YesNo

SECOND LAST EMPLOYER

FROM:

TO:

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES (MONTH/YEAR) AND REASON

Were you subject to the Federal Motor Carner Safety Regulations (FMCSRs) while employed by the previous employer?YesNo

THIRD LAST EMPLOYER

FROM:

TO:

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES (MONTH/YEAR) AND REASON

Were you subject to the Federal Motor Carner Safety Regulations (FMCSRs) while employed by the previous employer?YesNo

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make sure investigations and inquiries to 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."

DATE:

Signature