ZumeForms - MooJuiceExpressApplication

Main Application Section

Personal Information

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Full Name

Social Security Number

Address

Date of Birth

Phone Number

City

State

Zip / PostCode

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Emergency Contact

Relationship

Phone Number

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Have you ever worked or applied here before?

Yes

If Yes, Date:

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Residence Addresses for the Past Three (3) Years

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Education

Have You Attended Truck-Driving School?

Yes

Graduation Date:

If Yes, Name of School

City

State

Zip

Highest Grade Completed

Last School Attended

Degrees & Honors Received

Additional Education

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Military Status

Have You Served in The Armed Forces?

Yes

If Yes, What Branch?

Date of Service From:

To:

Special Skills

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Driving Experience

In What States Have you Driven Regularly?

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Driving / Work Experience

PLEASE INCLUDE ALL DATES, INCLUDING UNEMPLOYED TIME, BEGINNING WITH YOUR MOST RECENT EMPLOYER. LIST ALL EMPLOYERS FOR THE PREVIOUS TEN (10) YEARS FOR CDL DRIVERS AND THREE (3) YEARS FOR NON-CDL DRIVERS.

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Previous Employment

Start Date:

End Date:

Reason for Leaving

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Were you required to Comply with the FMCSR’s?

Yes

Were you required to Submit to Drug / Alcohol Testing?

Yes

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Start Date:

End Date:

Reason for Leaving

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Were you required to Comply with the FMCSR’s?

Yes

Were you required to Submit to Drug / Alcohol Testing?

Yes

Add New

Start Date:

End Date:

Reason for Leaving

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Were you required to Comply with the FMCSR’s?

Yes

Were you required to Submit to Drug / Alcohol Testing?

Yes

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Start Date:

End Date:

Reason for Leaving

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Were you required to Comply with the FMCSR’s?

Yes

Were you required to Submit to Drug / Alcohol Testing?

Yes

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Driver's License Information

Have you ever Been Convicted of DWI, DUI, OWI, Careless or Reckless Driving?

Yes

If Yes, Date:

Has Your License (any) or Privilege to Drive Ever Been Suspended or Revoked for ANY Reason?

Yes

If Yes, Date:

Have you ever been convicted of any misdemeanor other than a traffic violation?

Yes

If Yes, Date:

Have you Ever Been Convicted of a Felony?

Yes

If Yes, Date:

List ALL Driver’s Licenses That You Presently Hold or Have Held in the Past Three (3) Years.

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License Number

State

Expiration

License Number

State

Expiration

License Number

State

Expiration

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Accidents

List and explain in detail, giving date, location of all accidents (regardless of fault) that you have been involved in during the past three (3) years in any type of vehicle. FAILURE TO LIST ALL ACCIDENTS MAY RESULT IN YOUR DISQUALIFICATION. If you have not been involved in any accidents in the past three (3) years write “None.”

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Date

Type of Vehicle

Approximate Damage

At Fault?

Yes

Injuries?

Yes

Fatalities?

Yes

Explanation

Date

Type of Vehicle

Approximate Damage

At Fault?

Yes

Injuries?

Yes

Fatalities?

Yes

Explanation

Date

Type of Vehicle

Approximate Damage

At Fault?

Yes

Injuries?

Yes

Fatalities?

Yes

Explanation

Date

Type of Vehicle

Approximate Damage

At Fault?

Yes

Injuries?

Yes

Fatalities?

Yes

Explanation

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Traffic Violations

I certify that the following is a true and complete list of all traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past three (3) years. FAILURE TO LIST ALL TRAFFIC VIOLATIONS MAY RESULT IN YOUR DISQUALIFICATION. If you have no traffic violation convictions or forfeited bonds in the past three (3) years write “None.”

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Type of Violation

Date

City

State

Penalty

Type of Violation

Date

City

State

Penalty

Type of Violation

Date

City

State

Penalty

Type of Violation

Date

City

State

Penalty

Type of Violation

Date

City

State

Penalty

Type of Violation

Date

City

State

Penalty

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Agreement

(Please read the following statements carefully.)

I understand that the company follows the practice of requiring driver applicants to successfully complete a physical examination (as prescribed by the Federal Motor Carrier Safety Regulation Section 391. 41) which includes a substance abuse test, as a term and condition of qualification and from time to time thereafter to submit to a alcohol or substance abuse test as specified in the Federal Motor Carrier Safety Regulations Section 382. Therefore, I hereby knowingly and freely give my consent to submit to a physical examination, including a substance abuse test, and further agree to submit to a random alcohol or substance abuse test from time to time when so requested. I understand that my inability to successfully complete a physical examination, and/or any alcohol or substance abuse test would be cause for denial of qualification or disqualification if qualified

In connection with my application for qualification (including contract for services) with you, I understand that consumer reports, which contain public record information, may be requested from Third Party providers including the Federal Motor Carrier Safety Administration. These reports may include the following types of information: work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, worker’s compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from other providers concerning previous driving records requests made by others from such state agencies and state provided driving records.

I have the right to make a request to Third Party providers, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which Third Party providers has previously furnished within the three year period preceding my request. I hereby consent to your obtaining the above information which Third Party providers has or obtains, and my employment history with you if I am qualified by you, will be supplied by Third Party providers to other companies which subscribe to other providers.

I hereby authorize procurement of consumer report(s). If qualified, this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my qualification period.

This certifies that this application was completed by me and that all entries on it and information in it are true and correct to the best of my knowledge. I also agree that falsified information or significant omissions may result in my disqualification now or at any time.

I understand I have the right to review information provided by past employer, have errors corrected by previous employer and resubmitted to this carrier and/or have a rebuttal statement attached to erroneous information if my previous employer and I cannot agree on the accuracy of the information. I understand I must request past employer information obtained by this carrier in writing within 30-days of my application date.

In accordance with Section 382.413 and 391.23 of the Federal Motor Carrier Safety Regulations, I hereby authorize any and all persons and/or institutions to provide any relevant information that may be required to complete my qualification.

Have you tested positive or refused a test on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

Yes

Have you ever tested positive or refused any drug or alcohol test during the past five years?

Yes

Driver Certification for Other Compensated Work:

Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations require a driver to report all on duty time including time working for other employers. This includes time performing any work in the capacity of, or in the employ or service of a motor carrier (including a private motor carrier) or a non-motor carrier.

Are you currently working for another motor carrier or non-motor carrier?

Yes

Do you intend to work for another motor carrier or non-motor carrier while working for this carrier?

Yes

Do you agree to notify this carrier if you do intend to work for another motor carrier or non-motor carrier while working for this carrier?

Yes

Type Full Name

Social Security Number

Today's Date

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Main Application Section

Personal Information

Residence Addresses for the Past Three (3) Years

Education

Military Status

Driving Experience

Driving / Work Experience

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Driver's License Information

Accidents

Traffic Violations

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Agreement

Agreement

Driver Certification for Other Compensated Work: