Employment

Driver Application

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex, national origin, age, marital status, or non-job related disability.

TO BE READ AND CONFIRMED BY APPLICANT

I understand that information I provide regarding current and/or previous employers and for those 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 CFR 391.23(d) and (e).

I also understand that 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

I have read and understand the above information.

Driver Contact Information

Last Name
First Name
Middle Name
Address
City
State
Zip
Phone Number
with area code
( )
Date of Birth
mm/dd/yyyy
Social Security Number

Previous Addresses for the Past Three (3) Years

Address
City
State
Zip
From
To
Address
City
State
Zip
From
To
Address
City
State
Zip
From
To

Work Experience

In accordance with §391.21 & .23 of the Federal Motor Carrier Safety Regulations (FMCSR), an applicant must list all previous work experience for the three (3) years prior to the date of application, as well as all commercial driving experience for seven (7) years prior to those three years, for a total of 10 years.

PLEASE LIST STARTING WITH MOST RECENT EMPLOYER, EMAIL TO SATTERM@HORIZONFREIGHTLINES.COM IF ADDITIONAL SPACE IS NEEDED.

Current or Last Employer

Company Name
Address
City
State
Phone Number
with area code
( )
Fax
Email
Supervisor Name
Reason for Leaving
Job Description
From
To
Was this job designated as a safety sensitive function in an DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40?
1. Yes
2. No
*Was this job subject to FMCSA Regulations?
1. Yes
2. No
**Account for Period Between Jobs - Include dates (month/year) and reason

Second Last Employer

Company Name
Address
City
State
Phone Number
with area code
( )
Fax
Email
Supervisor Name
Reason for Leaving
Job Description
From
To
Was this job designated as a safety sensitive function in an DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40?
1. Yes
2. No
*Was this job subject to FMCSA Regulations?
1. Yes
2. No
**Account for Period Between Jobs - Include dates (month/year) and reason

Third Last Employer

Company Name
Address
City
State
Phone Number
with area code
( )
Fax
Email
Supervisor Name
Reason for Leaving
Job Description
From
To
Was this job designated as a safety sensitive function in an DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40?
1. Yes
2. No
*Was this job subject to FMCSA Regulations?
1. Yes
2. No
**Account for Period Between Jobs - Include dates (month/year) and reason

* The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: 1) weighs or has GVWR of 10,001 pounds or more, 2) is designed or used to transport 9 or more passengers, or 3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
** Any gaps in employment and/or unemployment must be explained.

Commercial Driver's License Information

License #
Type
State
Exp. Date
mm/dd/yyyy
Endorsements
check all that apply
1. Double/Triple Trailers
2. Tank Vehicles
3. Passenger Vehicles
4. Hazardous Materials

List any additional license(s) held in the past 3 years

State
Exp. Date
mm/dd/yyyy
State
Exp. Date
mm/dd/yyyy

Has your permit, CDL, or privilege to operate a motor vehicle ever been denied, suspended, or revoked?
1. Yes
2. No
If yes, explain

Collisions

Please list all motor vehicle collisions in which you were involved (both commercial and private vehicle) during the past three years prior to the application date. If none, type "none."

Collision 1

Date
mm/dd/yyyy
Description
State
# of Injuries
# of Fatalities
Haz. Mat. Spill
1. Yes
2. No

Collision 2

Date
mm/dd/yyyy
Description
State
# of Injuries
# of Fatalities
Haz. Mat. Spill
1. Yes
2. No

Collision 3

Date
mm/dd/yyyy
Description
State
# of Injuries
# of Fatalities
Haz. Mat. Spill
1. Yes
2. No

Traffic Convictions and Forfeitures

Please list all traffic convictions and/or forfeitures (both commercial and private vehicle) for the past three years (other than parking). If none, type "none."

Incident 1

Date
mm/dd/yyyy
Location
Charge
Penalty

Incident 2

Date
mm/dd/yyyy
Location
Charge
Penalty

Incident 3

Date
mm/dd/yyyy
Location
Charge
Penalty

Driving Experience

Straight Truck

Type of Equipment

Dates or Approx. Miles Driven

From
miles
To

Tractor & Semi Trailer

Type of Equipment

Dates or Approx. Miles Driven

From
miles
To

Other

Type of Equipment

Dates or Approx. Miles Driven

From
miles
To

List Commodities Hauled

Education

Please select the highest grade completed.
1 2 3 4 5 6 7 8 9 10 11 12
College: 1 2 3 4
Other Training
Have you received any safety awards or special training?
Do you have full knowledge of the Federal Motor Carrier Safety Regulations?
1. Yes
2. No

General

Have you been a driver for this company before?
1. Yes
2. No
If so, when?
Where?
Is there any reason you might be unable to perform the functions of the job for which you have applied?
1. Yes
2. No
Have you ever been convicted for DUI, DWI, or OUI?
1. Yes
2. No

In case of emergency, contact:

Name
Phone Number
with area code
( )
Relationship

MUST BE READ AND AGREED UPON BY THE APPLICANT

I authorize the carrier to make such inquiries and investigations of my personal, employment, driving, 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 agree to abide by the rules and regulations of the carrier as well as the Federal Motor Carrier Safety Regulations. I also agree and understand that if I am selected to drive for the carrier that I will be on a probationary period during which time I may be discharged without recourse.

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.

Horizon Freight Lines, Inc.
6579 South U.S. 31, Edinburgh, IN 46124

800-621-7875
812-526-3380