Application-CDL-DOT-1 (pdf) – Pitt Construction

CDL APPLICATION

Terry R Pitt Construction, Inc.

Applicant Name

Date

Current Address

City, State, Zip

Phone Number

How did you hear about us?

Are you at least 21 years old?

Yes No

Can you provide proof of age?

Yes No

Previous Addresses (provide 3 years):

Street

City, State, Zip

Street

City, State, Zip

Street

City, State, Zip

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job-related disability, or any other protected group status.

To be read and signed by applicant

I authorize you to make such investigations and inquires 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 Terry R Pitt Construction, Inc. has a Drug Alcohol and Substance Use/Abuse policy and that any offered employment is conditional upon successful passing of a drug screening test. 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 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 erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

Lastly, I certify 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.

I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may be rendered for refusal of this application or immediate termination of employment

I Agree

Application to Complete

Position Applying for:

(Optional) Please circle the following. Are you:

African American Hispanic American American Indian Asian American White Native American/Alaskan Native Pacific Islander Two or More Races Other

Do you have the legal right to work in the United States?

Yes No

Can read and speak the English language sufficiently to converse with the general public, to understand highway traffic signs and signals in the English language, to respond to official inquiries, and to make entries on reports and records

Yes No

Are you currently employed?

Yes No

If not, how long since leaving last employment?

Date available for work

Who referred you?

Rate of Pay Expected

Have you ever been convicted of a Felony?

Yes No

If yes, please explain:

Driver’s License Information: List all licenses held within the previous 3 years.

License Number

Class

Class A Class B Class C

Endorsements

Tanker Hazmat Doubles triples

State

License Number

Exp. Date

Class

Class A Class B Class C

Endorsements

Tanker Hazmat Doubles triples

State

License Number

Exp. Date

Class

Class A Class B Class C

Endorsements

Tanker Hazmat Doubles triples

State

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

If the answer to either of the previous questions is yes, give a statement of the details below:

Have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

Yes No

If YES - Have you successfully completed the return-to-duty process?

Yes No

Driving Experience

Equipment Type

To Date

Date From

Approximate mileage

Equipment Type

To Date

From Date

Approximate Mileage

Equipment Type

To Date

From Date

Approximate Mileage

Equipment Type

To Date

From Date

Approximate Mileage

List all Traffic Violations Convictions for the Previous 3 years

Date

Location

Violation

Commercial Vehicle

Yes No

Date

Location

Violation

Commercial Vehicle

Yes No

Date

Location

Violation

Commercial Vehicle

Yes No

Date

Location

Violation

Commercial Vehicle

Yes No

Date

Location

Violation

Commercial Vehicle

Yes No

Date

Location

Violation

Commercial Vehicle

Yes No

List all Accidents for the previous 3 years

Date

Nature of Accident (Head-on, Rear-end, Upset, etc.)

Fatalities

Injuries

Date

Nature of Accident (Head-on, Rear-end, Upset, etc.)

Fatalities

Injuries

Date

Nature of Accident (Head-on, Rear-end, Upset, etc.)

Fatalities

Injuries

Date

Nature of Accident (Head-on, Rear-end, Upset, etc.)

Fatalities

Injuries

Employment History

List all employment for the previous 3 years, all driving jobs for the previous 10 years, including any gaps between employers.

Employer

Dates

Supervisor

Phone

Address

Job Title and Duties

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes No

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes No

Employer

Dates

Supervisor

Phone

Address

Job Title and Duties

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes No

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes No

Employer

Dates

Supervisor

Phone

Address

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes No

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes No

Military Status

Have you served in the US Armed Forces

Yes No

Branch

Army Navy Marines Coast Guard Air Force Space Force

Education

Circle Highest Grade Completed:

1 2 3 4 5 6 7 8 9

High School:

1 2 3 4

College:

1 2 3 4

Description of vehicles driver intends to drive:

VEHICLE TYPE

truck truck tractor bus

IF BUS, INDICATE SEATING

CAPACITY

MAKE

MODEL#

YEAR

TRANSMISSION TYPE

Automatic Manual

# OF FORWARD SPEEDS

IF EQUIPPED WITH AUXILIARY TRANSMISSION, INDICATE:

NUMBER OF FORWARD SPEEDS

REAR AXLE SPEED

Designate single speed 2 speed 3 speed

TYPE OF BRAKE SYSTEM

STEERING

Manual Power assisted

NUMBER OF SEMITRAILERS OR FULL TRAILERS TO BE TOWED AT ONE TIME

DESCRIPTION OF TRAILER(S)

van flatbed cargo tank lowboy pole dump etc.

DESCRIPTION OF VEHICLE MODIFICATIONS

List other equipment you can operate and years’ experience of each

Trackhoe Backhoe Forklift

Course or Training Completed

OSHA CPR PEC/Safeland MSHA

For Driver applicants of commercial motor vehicles that require a Commercial Driver’s License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).

Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer provided investigation information, must submit a written request to the prospective employer, which may be done at any time, including when applying or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five (5) business day deadline will begin when the perspective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.

I CERTIFY THAT I AM OTHERWISE QUALIFIED UNDER PART 391 (QUALIFICATION OF DRIVERS) OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS. I ALSO CERTIFY 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.

Certification

I Agree

Date

Attachments