DATE OF APPLICATION: ____/____/_____

APPLICATION

AMT TRUCKING, INC. 
3835 S. 500 E.
LAFAYETTE, IN 47909

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex, national origin, age, marital status, or non-job related disability. 
                     	
TO BE READ AND SIGNED BY APPLICANT

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 also 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 alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information

Applicant Signature: X______________________________________________		Date ____/____/____

DRIVER NAME_____________________________________________________________________________________________
			(LAST)				(FIRST)			(MIDDLE)
ADDRESS__________________________________________________________________________________________________
CITY______________________________________________________, STATE____________________, ZIP_________________
TELEPHONE NUMBER (______) _______ - ____________	CELL PHONE NUMBER (______) _______-______________
DATE OF BIRTH _____/____/_____        SOCIAL SECURITY NUMBER __ __ __ - __ __ - __ __ __ __

PREVIOUS ADDRESSES FOR THE PAST THREE (3) YEARS

1) ADDRESS ______________________________________________________________________________________________
    CITY_______________________________________,STATE_____,ZIP____________ FROM ___________ TO ___________
2) ADDRESS ______________________________________________________________________________________________
    CITY_______________________________________,STATE_____,ZIP____________ FROM ___________ TO ___________
3) ADDRESS ______________________________________________________________________________________________
    CITY_______________________________________,STATE_____,ZIP____________ FROM ___________ TO ___________

HAVE YOU EVER BEEN CONVICTED OF A FELONY? _______________________________

IF YES, WHAT WAS THE CONVICTION & YEAR?____________________________________________________________

WORK EXPERIENCE

In accordance with §391.21 & .23 of the Federal Motor Carrier Safety Regulations (FMCSR), an applicant must list all previous work experience for the three (3) years prior to the date of application shown on page one, as well as all commercial driving experience for seven (7) years prior to those three years, for a total of 10 years.  If you are an owner operator, list carriers leased to.
 PLEASE LIST STARTING WITH MOST RECENT EMPLOYER, USE ADDITIONAL SHEET IF NEEDED.

CURRENT OR LAST EMPLOYER COMPANY NAME:____________________________________________________________________
ADDRESS:__________________________________________,CITY________________________________  STATE_______  ZIP__________
PHONE:___________________________________  FAX:_____________________________  E-MAIL:________________________________
SUPERVISOR NAME:______________________________ REASON FOR LEAVING?_____________________________________________ 
JOB DESCRIPTION: ______________________________________________________   FROM: _____/_____/_____ TO: _____/_____/_____  

Were you subject to controlled substances and alcohol testing specified by 49 CFR Part 40 during this period?  YES  NO
*Was this job subject to FMCSA Regulations?  YES   NO

**ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason _______________________________________________
_______________________________________________________________________________________________________________________

SECOND LAST EMPLOYER COMPANY NAME:____________________________________________________________________
ADDRESS:__________________________________________,CITY________________________________  STATE_______  ZIP__________
PHONE:___________________________________  FAX:_____________________________  E-MAIL:________________________________
SUPERVISOR NAME:______________________________ REASON FOR LEAVING?_____________________________________________ 
JOB DESCRIPTION: ______________________________________________________   FROM: _____/_____/_____ TO: _____/_____/_____  

Were you subject to controlled substances and alcohol testing specified by 49 CFR Part 40 during this period?  YES  NO
*Was this job subject to FMCSA Regulations?  YES   NO

**ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason _______________________________________________
_______________________________________________________________________________________________________________________

THIRD LAST EMPLOYER COMPANY NAME:____________________________________________________________________
ADDRESS:__________________________________________,CITY________________________________  STATE_______  ZIP__________
PHONE:___________________________________  FAX:_____________________________  E-MAIL:________________________________
SUPERVISOR NAME:______________________________ REASON FOR LEAVING?_____________________________________________ 
JOB DESCRIPTION: ______________________________________________________   FROM: _____/_____/_____ TO: _____/_____/_____  

Were you subject to controlled substances and alcohol testing specified by 49 CFR Part 40 during this period?  YES  NO
*Was this job subject to FMCSA Regulations?  YES   NO

**ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason _______________________________________________
_______________________________________________________________________________________________________________________

* 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 9 or more passengers, or 3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
**Any gaps in employment and/or unemployment must be explained. 

COMMERCIAL DRIVER’S LICENSE INFORMATION

LICENSE #_________________________________	  TYPE _________  STATE _____  EXP. DATE _______/_______/_______
						           (A,B, OR C)

ENDORSEMENTS (check all that apply):	DOUBLE/TRIPLE TRAILERS		TANK VEHICLES
					PASSENGER VEHICLES		HAZARDOUS MATERIALS

LIST ANY ADDITIONAL LICENSE(S) HELD IN THE PAST 3 YEARS:
STATE:  ____    NUMBER:  _____________________	EXPIRATION DATE:  ________/________/________
STATE:  ____    NUMBER:  _____________________	EXPIRATION DATE:  ________/________/________

HAS YOUR PERMIT, CDL, OR PRIVILEGE TO OPERATE A MOTOR VEHICLE EVER BEEN DENIED, SUSPENDED, OR REVOKED OR CANCELLED?	NO	YES	IF YES, EXPLAIN_________________________________________________

COLLISIONS

PLEASE LIST ALL MOTOR VEHICLE COLLISIONS IN WHICH YOU WERE INVOLVED (BOTH COMMERCIAL AND PRIVATE VEHICLE) DURING THE PAST THREE YEARS PRIOR TO THE APPLICATION DATE. IF NONE, WRITE “NONE”

   								# OF		# OF
  DATE	                        DESCRIPTION		        STATE	INJURIES	FATALITIES	HAZ.MAT.SPILL	
___/____/____     _____________________________     _______	________	___________	NO	YES
___/____/____     _____________________________     _______	________	___________	NO	YES
___/____/____     _____________________________     _______	________	___________	NO	YES

TRAFFIC CONVICTIONS AND FORFEITURES

PLEASE LIST ALL TRAFFIC CONVICTIONS AND/OR FORFEITURES (BOTH COMMERCIAL AND PRIVATE VEHICLE) FOR THE PAST THREE YEARS (OTHER THAN PARKING). IF NONE, WRITE “NONE”

DATE                    STATE         VIOLATION	                   	        PENALTY         COMMERCIAL VEHICLE?
____/____/____    ________      ________________________________       _________         NO	YES
____/____/____    ________      ________________________________       _________         NO	YES
____/____/____    ________      ________________________________       _________         NO	YES
____/____/____    ________      ________________________________       _________         NO	YES

DRIVING EXPERIENCE

EQUIPMENT CLASS	                	    TYPE OF EQUIPMENT	        DATES                   	APPROX. MILES
		                                             (VAN, TANK, FLAT, ETC.)         FROM       TO       or       	        DRIVEN
STRAIGHT TRUCK 	    		_______________________	______   ______		 ________________
TRACTOR & SEMI TRAILER		_______________________	______   ______ 		 ________________
OTHER					_______________________	______   ______		 ________________
LIST COMMODITIES HAULED: ______________________________________________________________________________

EDUCATION

PLEASE CIRCLE THE HIGHEST GRADE COMPLETED:  1 2 3 4 5 6 7 8 9 10 11 12    COLLEGE: 1 2 3 4 

OTHER TRAINING : _____________________________________________________________________________________

HAVE YOU RECEIVED ANY SAFETY AWARDS OR SPECIAL TRAINING? _____________________________________   

DO YOU HAVE FULL KNOWLEDGE OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS? YES	NO

GENERAL

HAVE YOU BEEN A DRIVER FOR THIS COMPANY BEFORE?	YES	NO
IF SO, WHEN?  _____/_____	WHERE? _____________________________________________________________________
IS THERE ANY REASON YOU MIGHT BE UNABLE TO PERFORM THE FUNCTIONS OF THE JOB FOR WHICH YOU HAVE APPLIED?						YES	NO
HAVE YOU EVER BEEN CONVICTED FOR DUI, DWI OR OUI?	YES	NO
IN CASE OF EMERGENCY, CONTACT: _________________________ (___)___________________  _____________________
						Name			Telephone number	Relationship

MUST BE READ AND SIGNED BY THE APPLICANT

I authorize the carrier to make such inquiries and investigations of my personal, employment, driving, 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 agree to abide by the rules and regulations of the carrier as well as the Federal Motor Carrier Safety Regulations.  I also agree and understand that if I am selected to drive for the carrier that I will be on a probationary period during which time I may be discharged without recourse.

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.

X____________________________________________________		_____/_____/_____
                                    Applicant Signature                                                 		Date