In compliance with Federal and State equal employment 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 inquiries 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 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 CFR391.23(d) and (e). I understand 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.

Answer all questions-Please printAPPLICANT TO COMPLETE

List your addresses of residency for the past three (3) years

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* Required for commercial drivers

* conviction of a crime is not an automatic bar to Employment-all circumstances will be considered.

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding three (3) years. List complete mailing address, street number, city, state, and zip code.

Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional seven (7) years' information on those employers for whom the applicant operated such vehicle.

( NOTE: List employers in reverse order beginning with the most recent. Add another sheet if necessary )

Employer

* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

** The Federal Motor Carrier Safety Regulations (FMCSR) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weights or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport nine (9) or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Dates Nature of accident (head-on, rear-end, upset, etc.) Fatalities Injuries Hazardous material spill
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Traffic convictions and forfeitures for the past three (3) years ( other than parking violations ). if none, write none. attach additional sheet if more space is needed

Location Date Charge Penalty
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Experience and qualifications-driver. ( list all driver licenses or permits held in the past three (3) years. )

State License number Type Expiration date
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Driving experience: check yes or no as to each type of equipment

Class of equipment Circle type of equipment Dates Expiration date

Experience and qualifications-other

Education

Circle highest grade completed

To be read and signed by applicant

This certifies that this application was completed by me, and that all entries on it and information contained therein are true and complete to the best of my knowledge.

Tsi trucking, llc

PREVIOUS EMPLOYMENT VERIFICATION FORM

The above applicant has listed your company as a previous employer. Please complete as much information as possible on the verification form below:

Dates Nature of accident (head-on, rear-end, upset, etc.) Preventable Injuries / Fatalities Amount
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If yes to DOT violations, please provide documentation of employee's successful completion of DOT return-to-duty requirements (including follow-up drug and alcohol tests).

I hereby authorize you to release the following information to TSI, LLC for purpose of investigations as required by Sec 391.33 and 383.413 of Federal Motor Carrier's Safety Regulations. You are released from any and all liability, which may result from furnishing this information.