Applicant name
Date of application
W2 Logistic, Inc. 1100 N Ellis St., Bensenville, IL 60106
To Be Read and Signed by Applicant:
I acknowledge that the company to which I am applying is an Equal Opportunity Employer and will recruit, hire, promote, and train for all jobs without regard to race, color, religion, sex, origin, age, marital status, veteran status, non-job related disability, or any other protected group status.
I hereby authorize the motor carrier or his agents to make such investigations and inquires of my personal, employment, medical or financial history and other related information 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.
I understand that: any falsified information or omission of facts may cause for denial of employment or will be grounds for dismissal if employed; I am required to abide by all rules and regulations of the Company and; information I provide regarding previous and/or current employer(s) may be used for the purpose of investigating my safety performance history, and those employer(s) will be contacted as required by paragraphs (d) and (e) of 49 CFR 391.23;
I have the following rights:
- The right to review information provided by previous employers;
- The right to have errors in the information corrected by the previous employers and for those previous employers to re-send the corrected information to the prospective employer;
- The right to 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.
Signature
Date
APPLICANT TO COMPLETE
Please answer all questions
Position(s) applied for
Last Name
First Name
Middle Name
Social Security No.
List of your addresses of residency for the past 3 years
Current Address
Street/City
State/Zip
How long? (yr./mo.)
Phone
Email
Previous Address Click to show
Previous Address Click to show
Previous Address Click to show
Do you have the legal right to work in the United States YES NO
Date of Birth
Can you provide proof of age?
Have you worked for this company before
Where?
From
To
Rate of Pay
Position
Reason for leaving
Are you now employed? YES NO
If not, how long since leaving last employment?
Who reffered you?
Rate of pay expected
Have you ever been bonded?
Name of bonding company
Is there any reason you might be unable to perform the functions of the job which you have applied ?
If yes, explain if you wish
EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding 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 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent.)
Employer
From (Month/Year)
To (Month/Year)
Street and City
State
Zip
Position held
Salary/Wage
Contact person
Phone number
Reason for leaving
Were you subject to the FMCSRs while employed? YES NO
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? YES NO
Employment history Click to show
Employment history Click to show
Employment history Click to show
Employment history Click to show
Employment history Click to show
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE.
If none, please put a check by "none" NONE
Previous accident Click to show
Previous accident Click to show
Previous accident Click to show
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
If none, please put a check by "none" NONE
TRAFFIC CONVICTIONS AND FORFEITURES Click to show
TRAFFIC CONVICTIONS AND FORFEITURES Click to show
TRAFFIC CONVICTIONS AND FORFEITURES Click to show
EXPERIENCE AND QUALIFICATIONS - DRIVER
Driver licenses or permits held in the past 3 years.
State
License no.
Class/Endorsement's
Expiration date
State
License no.
Class/Endorsement's
Expiration date
State
License no.
Class/Endorsement's
Expiration date
State
License no.
Class/Endorsement's
Expiration date
A - Have you ever been denied a license, permit, or privilege to operate a motor vehicle? YES NO
B - Has any license, permit, or privilege ever been suspended or revoked? YES NO
If the answer to either A or B is yes, give details
DRIVING EXPERIENCE: STAIGHT TRUCK
Class of equipment: Straight truck
YES NO
Type of equipment
VAN TANK FLAT DUMP REFER
Date (FROM)
Date (TO)
Approx. no. of miles (TOTAL)
DRIVING EXPERIENCE: TRACTOR AND SEMI-TRAILER
Class of equipment: Tractor and semi-trailer
YES NO
Type of equipment
VAN TANK FLAT DUMP REFER
Date (FROM)
Date (TO)
Approx. no. of miles (TOTAL)
DRIVING EXPERIENCE: TRACTOR - TWO TRAILERS
Class of equipment: Tractor - two trailers
YES NO
Type of equipment
VAN TANK FLAT DUMP REFER
Date (FROM)
Date (TO)
Approx. no. of miles (TOTAL)
DRIVING EXPERIENCE: TRACTOR - THREE TRAILERS
Class of equipment: Tractor - three trailers
YES NO
Type of equipment
VAN TANK FLAT DUMP REFER
Date (FROM)
Date (TO)
Approx. no. of miles (TOTAL)
DRIVING EXPERIENCE: MOTORCOACH - SCHOOL BUS
Class of equipment: Motorcoach - school bus
YES NO
Type of equipment
VAN TANK FLAT DUMP REFER
Date (FROM)
Date (TO)
Approx. no. of miles (TOTAL)
DRIVING EXPERIENCE: MOTORCOACH - SCHOOL BUS OTHER
Class of equipment: Motorcoach - school bus other
YES NO
Type of equipment
VAN TANK FLAT DUMP REFER
Date (FROM)
Date (TO)
Approx. no. of miles (TOTAL)
List states operated in for the last five years:
Show special courses or training that will help you as a driver: If none write "NONE"
Which safe driving awards do you hold and from whom: If none write "NONE"
DRIVING EXPERIENCE: OTHER
Description: If none write "NONE"
EXPERIENCE AND QUALIFICATIONS - OTHER
Show any trucking, transportation or other experience that may help in your work for this company: If none write "NONE"
List courses and training other than shown elsewhere in this application: If none write "NONE"
List special equipment or technical materials you can work with (other than those already shown): If none write "NONE"
EDUCATION
Circle highest grade completed
1 2 3 4 5 6 7 8
High school
1 2 3 4 5
College
1 2 3 4 5
Last school attended
TO BE READ AND SIGNED BY APPLICANT:
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.
SIGN DATE
Submit
FOR COMPANY USE
PROCESS RECORD
APPLICANT HIRED
 
REJECTED
 
DATA EMPLOYED
 
POINT EMPLOYED
 
DEPARTMENT
 
CLASSIFICATION
 
(IF REJECTED, SUMMARY REPORT SHOULD BE PLACED IN FILE)
SIGNATURE OF INTERVIEWING OFFICER
 

TERMINATION OF EMPLOYEMENT
DATA TERMINATED
 
DEPARTMENT RELEASED FROM
 
DISMISSED
 
VOLUNTARILY QUIT
 
OTHER