DRIVER’S APPLICATION FOR EMPLOYMENT – Logistic Solutions Inc.

Date of Application//

SIN #

Postion Applied For

Driver
Second Choice

Corporation Name

Legal Status in Canada

Citizen
PR
Work Permit

WCB #

GST #

Full Name

Date of Birth//

Cell #

Home #

Email *

LAST YEAR ADDRESS HISTORY

From or Before

To

Address

Address Line 1

City

State / Province / Region

Postal Code

From or Before (copy)

To (copy)

Address (copy)

Address Line 1

City

State / Province / Region

Postal Code

DRIVER LICENSE INFORMATION

Issuing Province

Driver License Number

Driver License Class

Driver License Condition

Date / Time

1) Do you hold driver license in any other jurisdiction other than the mentioned above or do you hold any driver license in any other name?

Yes
No

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

Yes
No

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

Yes
No

4) Has you ever tested positive or refused to submit alcohol or controlled substance test?

Yes
No

5) Have you any injury or medical condition which might affect your job (convulsive disorder, epilepsy, fainting, or heart disease etc.)? *

Yes
No

DRIVING EXPERIENCE

Tractor Semi-Trailer

Years

Dry Van / Reefer

Years

Turn Pike / Super B

Years

Manual Transmission

Years

Chassis Trailer

Years

Long Haul

Years

Dump Truck

Years

Flatbed Trailer

Years

US Driving

Years

Straight Truck / 5 Ton

Years

Tanker / Bulk Trailer

Years

Winter Driving

Years

EMPLOYMENT HISTORY

Instructions :
(1) The applicant must provide the following information on all employers during the preceding 3 years.
(2) Provide additional 7 years infomation on those employers for whom the applicant operated commercial motor vehicle.
(3) Provide complete mailing address, street number, city, state, and postal code.
(4) Do not write “See resume" in this section.
(5) List employers in 'reverse order starting with the most recent. Add another sheet as necessary.

Start Date

End Date

Name of Employer

Complete Address

Contact Person

Contact Number

Position Held

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

Any gap in employment must be explained. Include dates and reason:

Start Date

End Date

Name of Employer

Complete Address

Contact Person

Contact Number

Position Held

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

Any gap in employment must be explained. Include dates and reason:

Start Date

End Date

Name of Employer

Complete Address

Contact Person

Contact Number

Position Held

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

Any gap in employment must be explained. Include dates and reason:

EMPLOYMENT HISTORY

Instructions :
(1) The applicant must provide the following information on all employers during the preceding 3 years.
(2) Provide additional 7 years infomation on those employers for whom the applicant operated commercial motor vehicle.
(3) Provide complete mailing address, street number, city, state, and postal code.
(4) Do not write “See resume" in this section.
(5) List employers in 'reverse order starting with the most recent. Add another sheet as necessary.

Start Date

End Date

Name of Employer

Complete Address

Contact Person

Contact Number

Position Held

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

Any gap in employment must be explained. Include dates and reason:

Start Date

End Date

Name of Employer

Complete Address

Contact Person

Contact Number

Position Held

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

Any gap in employment must be explained. Include dates and reason:

Start Date

End Date

Name of Employer

Complete Address

Contact Person

Contact Number

Position Held

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

Any gap in employment must be explained. Include dates and reason:

ACCIDENT RECORD

Accident record for past 3 years.

Date

Number of Fatalities

Location

Number of Injuries

Nature of Accident

Hazardous Material Spill

Yes
No

Date

Number of Fatalities

Location

Number of Injuries

Nature of Accident

Hazardous Material Spill

Yes
No

Date

Number of Fatalities

Location

Number of Injuries

Nature of Accident

Hazardous Material Spill

Yes
No

TRAFFIC CONVICTIONS

Traffic conviction penalties for the past 3 years.

Date

Location

Charge

Penalty ($)

Date

Location

Charge

Penalty ($)

Date

Location

Charge

Penalty ($)

TO BE READ AND SIGNED BY APPLICANT

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.

l authorize my prospect employer 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.

I agree that, if hired, I will immediately inform my employer in writing of any violations or accidents that occur while I am operating any motor vehicle. I will also immediately inform my employer of any suspensions, restrictions, prohibitions, or any other change in the status of my driver's licence.

By signing this application I certify 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. 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 have read the above stated terms and conditions.