Employment - Heirloom 93 Logistics

DRIVER EMPLOYMENT APPLICATION

First Name

Middle Name

Last Name

Phone Number

Date of Birth

SSN #

Date Available For Work

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

Previous 3 Years Residency

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years;

Driver Experience

Accident Record for the Past 3 Years

Traffic Convictions and Forfeitures For The Past 3 Years (Other than Parking Violations)

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

Has any license , permit, or privilege ever been suspended or revoked?

Current (Most Recent) Employer

Second (Most Recent) Employer

Third (Most Recent) Employer

Education

Other Qualifications

To Be Read and Accepted By Applicant

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior 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. 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 resend 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.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

Drivers License Front & Back

Medical DOT Card

Social Security Card

DRIVER EMPLOYMENT APPLICATION

Heirloom 93 Logistics

New Orleans, Louisiana

855-310-4643

info@heirloom93logistics.com

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