Personal Information
Full Name*
Date of Application*
Mobile Phone Number*
Email*
SSN*
Driver License No*
Driver License State*
—Please choose an option— AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Emergency Contact
Name
Phone Number
Relationship
General Information
Are you able to perform the essential job functions of the position for which you are applying or without reasonable accommodation?*
Yes No
Have you been convicted of any felonies other than minor traffic violations during the past seven years? (A criminal record or a conviction will not automatically bar employment, but will be considered only as it reasonably relates to your fitness to perform in the position for which you are applying.)*
Yes No
If Yes explain:
Previous Three Years Residency:
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.
Driving Experience
Straight Truck
Type of Equipment (Van, Flat, Bed, Tank, etc.)
From Date
To Date
Approx. No. of Miles (Total)
Tractor and Semi-Trailer
Type of Equipment (Van, Flat, Bed, Tank, etc.)
From Date
To Date
Approx. No. of Miles (Total)
Tractor Two-Trailer
Type of Equipment (Van, Flat, Bed, Tank, etc.)
From Date
To Date
Approx. No. of Miles (Total)
Other
Type of Equipment (Van, Flat, Bed, Tank, etc.)
From Date
To Date
Approx. No. of Miles (Total)
Accident Record For The Past 3 Years or More:
Nature of Accidents (Head-On, React-End, etc.)
Nature of Accidents (Head-On, React-End, etc.)
Nature of Accidents (Head-On, React-End, etc.)
Traffic Convictions and Forfeitures for The Past 3 Years(Other Than Parking Violations)
Violation
Violation
Violation
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes No
If Yes, explain:
Has any license, permit or privilege ever been suspended or revoked?
Yes No
If Yes, explain:
Education and Training
Last Grade Completed
—Please choose an option— 12 11 10 9 8 7 6 5 4 3 2 1
College
—Please choose an option— 4 3 2 1
Masters
—Please choose an option— Yes No
Doctorate
—Please choose an option— Yes No
Last High School Attended / Address
College or University / Address
Other Schools (Technical, Vocational, Gradute, etc.) / Address
List any scholarship, academic honors, awards, or special achievements:
Skills
Please list any skills you have that are appropriate for the position you are applying for:
Availability
If required, will you work?
Position
Salary Desired*
Date you can start*
Explain fully why you believe you are qualified for this position* :
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GENERAL CONSENT FOR LIMITED QUERIES OF THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION (FMCSA) DRUG AND ALCOHOL CLEARINGHOUSE
I, hereby provide consent to Rosstavi Freight Transport, Inc. to conduct limited query(s) of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug and/or alcohol violation information about me exists in the Clearinghouse. This consent shall be used to obtain one (1) query from the Clearinghouse during pre-employment/hiring process to determine eligibility, also to request a minimum of one (1) query per year (12 month) to complete annual review. This consent shall remain in effect if hire, until the end of my employment with Rosstavi Freight Transport, Inc. or until I request in writing to Rosstavi Freight Transport, Inc. the release of this consent.
I understand that if the limited query conducted by Rosstavi Freight Transport, Inc. indicates that drug and/or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Rosstavi Freight Transport, Inc. without first obtaining additional specific consent from me.
I further understand that if I refuse to provide consent for Rosstavi Freight Transport, Inc. to conduct a limited query of the Clearinghouse, Rosstavi Freight Transport, Inc. must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.
Applicant's Signature*
Applicant's Full Name*
Date*
Click here if you haven't registered for Clearinghouse.
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THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS PSP Disclosure
In connection with your application for employment with Rosstavi Freight Transport, Inc. (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).
When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.
When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.
Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.
Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
The Prospective Employer cannot obtain background reports from FMCSA without your authorization.
Authorization
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Rosstavi Freight Transport, Inc. (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.
I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.
I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.
I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Applicant's Signature*
Applicant's Full Name*
Date*
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.
NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49 C.F.R. 383.5.
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I hereby authorize the release of any and all information to Rosstavi Freight Transport, Inc. concerning my performance, conduct, accident record and all required DOT drug and alcohol related information while previously employed as a commercial motor vehicle operator in the previous 3 years from the date of this form as specified and required by the Federal Motor Carrier Safety Administration (FMCSA), Part 391.23 investigation and inquires. In connection with, and for the duration of, my employment (including contract for services) with you, I understand that investigative background inquiries are to be made on myself including consumer, driving, and other reports. Further, I understand that you might be requesting information from various federal, state, and other agencies which maintain records concerning my past activities relating to my driving, credit, civil and other experiences as well as notable criminal activity & claims involving me in the files of insurance companies. This release may also be used to obtain worker’s compensation and education records.
Applicant's Signature*
Applicant's Full Name*
Date*
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