PRE-APPLICATION
FOR DRIVER QUALIFICATION
800-844-4225
NOTE: All questions in *red are required
to be answered. |
| PERSONAL
INFORMATION |
*First Name:
|
*Last Name:
|
|
|
*Social Security
Number:
|
*Date of Birth:
|
*Birth
Year:
|
*Home
Phone (or # to be reached at):
|
Alt/cell Number:
|
*E-mail
Address:
|
*Are
You Currently Employed?
|
Yes |
|
No |
*Position
Applying For:
|
*How Did You
Hear About Us?
|
*Average Expected Weekly Gross Income:
|
| *Traffic lanes preferred:
|
*Home time preferred:
|
| *Average miles per week preferred:
|
*Avg. length of haul preferred:
|
| DRIVING EXPERIENCE
INFORMATION |
*Drivers License
Number:
|
*State:
|
| *Do you have a
Class A Commercial Drivers License? |
Yes |
No |
| *Do you have a
Hazardous Material Endorsement? |
Yes |
No |
| *Have you been
convicted of a DWI or DUI in the past 5 years? |
Yes |
No |
| *Have you ever
been convicted of a felony? |
Yes |
No |
| *Has your license
ever been suspended in last 3 years? |
Yes |
No |
| *Ever been disqualified
to drive by Federal Regulations? |
Yes |
No |
*# of Tickets in
the past 3 years (0-99)?
*# of tickets 15 MPH or over?
|
*# of Accidents
in the past 3 years(0-99)?
|
| *Verifiable Tractor-Trailer Over-the-Road
Experience? |
Yrs
Months |
None |
| *Verifiable Tractor-Trailer
VAN/REFER Experience? |
Yrs
Months |
None |
| *If you graduated from a driving school please give dates
|
Name of School |
City/State |
| *Have you ever hauled Steel coils? |
Yes |
No |
| If yes with whom?
|
| *Verifiable Tractor-Trailer
Flatbed Experience? |
Yrs
Months |
None |
Please List What you have hauled on
a Flatbed or Specialized Trailer?
|
| TRACTOR & TRAILER INFORMATION |
| *Owner:
|
*Doing Business As:
|
*Mailing Address:
|
*City:
|
*State:
|
*Zip Code:
|
*Home
Phone (or # to be reached at):
|
Alt/cell Number:
|
*Federal ID#:
|
| Trailer 1 |
Tractor Serial#:
|
Make:
|
Year:
|
Model:
|
| Monthly Payment $
|
Date Purchased:
|
| Trailer 2 |
Tractor Serial#:
|
Make:
|
Year:
|
Model:
|
| Monthly Payment $
|
Date Purchased:
|
| EMPLOYMENT
HISTORY |
D.O.T. requires
us to verify your past 3 Years of Employment History.
You must include all Driving & Non-Driving Jobs you have held
in the last 3 Years. Every month of employment must also be accounted for.
This will allow us to process your application as quickly
as possible. Thank You! |
*May We Contact Your Current
Employer:
|
Yes |
No |
| CURRENT OR LAST COMPANY |
| *Dates Employed: |
*From (Month/Year):
|
*To (Month/Year):
|
*Reason for leaving:
|
| *Company:
|
*Rate of Pay:
|
(start)
(current)
|
*City:
|
*State:
|
*Phone Number [ example: (xxx)
xxx-xxxx ]:
|
|
*Position Held:
|
*# of Accidents / Incidents:
|
*Equipment Driven:
|
*# of States Driven In:
|
| *Explain why no longer employed or looking to leave:
|
| SECOND LAST COMPANY |
| Dates Employed: |
From (Month/Year):
|
To (Month/Year):
|
Reason for leaving:
|
| Company:
|
Rate of Pay:
|
(start)
(ending)
|
City:
|
State:
|
Phone Number [ example: (xxx) xxx-xxxx ]:
|
|
Position Held:
|
# of Accidents / Incidents:
|
Equipment Driven:
|
# of States Driven In:
|
| Explain reason for leaving:
|
| THIRD LAST COMPANY |
| Dates Employed: |
From (Month/Year):
|
To (Month/Year):
|
Reason for leaving:
|
| Company:
|
Rate of Pay:
|
(start)
(ending)
|
City:
|
State:
|
Phone Number [ example: (xxx) xxx-xxxx ]:
|
|
Position Held:
|
# of Accidents / Incidents:
|
Equipment Driven:
|
# of States Driven In:
|
| Explain reason for leaving:
|
| FOURTH LAST COMPANY |
| Dates Employed: |
From (Month/Year):
|
To (Month/Year):
|
Reason for leaving:
|
| Company:
|
Rate of Pay:
|
(start)
(ending)
|
City:
|
State:
|
Phone Number [ example: (xxx) xxx-xxxx ]:
|
|
Position Held:
|
# of Accidents / Incidents:
|
Equipment Driven:
|
# of States Driven In:
|
| Explain reason for leaving:
|
| FIFTH LAST COMPANY |
| Dates Employed: |
From (Month/Year):
|
To (Month/Year):
|
Reason for leaving:
|
| Company:
|
Rate of Pay:
|
(start)
(ending)
|
City:
|
State:
|
Phone Number [ example: (xxx) xxx-xxxx ]:
|
|
Position Held:
|
# of Accidents / Incidents:
|
Equipment Driven:
|
# of States Driven In:
|
| Explain reason for leaving:
|
| OTHER INFORMATION |
|
*Consent to Run DAC Report
and MVR:
Yes
No
Please give reasons for interest in Riechmann
Transport :
Additional Commments:
I certify that I personally completed this application
and that all of the information is true and correct. I authorize
Riechmann Transport, Inc. to conduct a thorough background investigation
in accordance with state and federal law and authorize my previous
employers to release any information requested by Riechmann
Transport, Inc. and will not hold them responsible for any liability
from the release of said information. In accordance with provisions
of 49 CFR Part 382.405 and 382.413, I hereby authorize and require
my previous and/or current employers specifically listed by
me on this application to release the results (including the
refusal to test) of all drug and alcohol tests taken by me pursuant
to the provisions of 49 CFR while in their employment to Riechmann
Transport, Inc. by whatever means is most timely.
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