Paul Terry Trucking Company, Inc. - Employment Application
The purpose of this document is to determine whether or not the applicant meets all requirements set by Paul Terry Trucking Company, Inc. and the Federal Motor Carrier Safety Regulations when applicable.


Instructions to Applicant
Please answer all questions. If the answer is no or does not apply please do not leave the item blank, simply enter "no" or "n/a".


General Information
Drivers License Expiration
State of Issue
Do you have a current DOT Physical Card?
DOT Physical Card Expiration Date
Residence History
Give a complete three (3) year residence history.


State
Zip Code
Does this complete your three (3) year residence history?
State
Zip Code
Does this complete your three (3) year residence history?
State
Zip Code
Does this complete your three (3) year residence history?
Residence History Cont.
If you were unable to complete your three (3) year residence history please upload a file completing your history.
Upload your documents...
Education History
Please provide your education history.


Grade School
  • - select a option -
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  • 5
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  • 7
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  • 9
  • 10
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College
  • - select a option -
  • 0
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Post-Graduate
  • - select a option -
  • 0
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Employment History
Give a Complete Record of all employment for the past three (3) years, including any unemployment or self employment, and ALL commercial driving experience for the past ten (10) years.


Telephone Number
Were you subject to the FMCSR's while employed here?
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?
*The Federal Motor Carrier Safety Regulations (FMCSR's) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle (1) has a CVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.


City
State
Reason for Leaving
Does this complete your three (3) year employment history and ten (10) year commercial driving history?
Telephone Number
Were you subject to the FMCSR's* while employed here?
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?
*The Federal Motor Carrier Safety Regulations (FMCSR's) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle (1) has a CVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.


City
State
Reason for Leaving
Does this complete your three (3) year employment history and ten (10) year commercial driving history?
Telephone Number
Were you subject to the FMCSR's* while employed here?
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?
*The Federal Motor Carrier Safety Regulations (FMCSR's) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle (1) has a CVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.


City
State
Reason for Leaving
Does this complete your three (3) year employment history and ten (10) year commercial driving history?
Telephone Number
Were you subject to the FMCSR's while employed here?
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?
*The Federal Motor Carrier Safety Regulations (FMCSR's) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle (1) has a CVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.


City
State
Reason for Leaving
Does this complete your three (3) year employment history and ten (10) year commercial driving history?
Employment History Cont.
If you were unable to complete your employment history please upload a file completing your history.
Upload your documents...
Driving Experience
Please complete each section of Driving Experience to the best of your ability.


Class of Equipment
From
To
Approximate Number of Miles (Total)
List all states operated in for the last five years.
List any special courses/training completed. (PTD/DDC, Haz Mat, Twic , etc)
List any safe driving awards and from whom they were awarded.
Accident History
Please provide a complete listing of any accident in the past ten (10) years.


Date
Location
Nature of Accident (Head on, Rear end, etc)
# of Injuries
# of Fatalities
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
B. Has any license, permit or privilege ever been suspended or revoked?
C. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?
D. Have you ever been convicted of a felony?**
** Disclosure of this information does not automatically exclude the applicant from consideration.
If the answers to A, B, C or D is "Yes" please give details.
To Be Read and Signed by Applicant

It is agreed and understood that any misrepresentation given on this document shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate my background to ascertain any and all information of concern to commercial driving record, whether same is of record or not, and I release the employers and persons named herein from all liability for any damages on account of their furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

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



Applicant Signature
Date
Driver's Rights Pertaining To Release Of Driver Information Under Regulation 391.23

Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.

• (a)(1) An inquiry into the driver’s driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator’s license or permit during those three years; and,

• (a)(2) An investigation of the driver’s employment record during the preceding three years.

• (b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver’s employment begins and be retained in compliance with 391.51.

• (c) Replies to the investigations of the driver’s safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver’s employment begins. This goes into effect after October 29, 2004.

• (d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.

• (e) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.

Drivers have the following rights: 1. The right to review information provided by previous employers. 2. The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer. 3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver’s request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver’s Safety Performance History.


I acknowledge that I have read and understand the contents of this document.



Applicant Signature
Date
Applicant Drug and Alcohol Pre-Employment Statement

CFR Part 40.25(j) requires the employer to ask any driver applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, employers must not use the employee, if hired, to perform safety-sensitive functions, until and unless the potential employee provides documentation of successful completion of the return-to-duty process. (See CFR 40.25(b)(5) and (e)).

Applicant Signature
Date
Controlled Substance & Alcohol Testing Information Acknowledgement/Consent Form

As a condition of employment with Paul Terry Trucking Company, Inc., commercial motor vehicle (CMV) driver applicants, who will perform safety-sensitive functions, must submit to a pre-employment controlled substances test as required by the Federal Motor Carrier Safety Regulations (FMCSR) Section 382.301. A motor carrier must receive verified negative test results for the applicant driver for the applicant to be eligible for employment.

If you are hired, you will be subject to laws requiring additional controlled substances and alcohol testing on you under numerous situations including, but not limited to, the following:


Post-Accident – Section 382.303
Random – Section 382.305
Reasonable-Suspicion – Section 382.307
Return to Duty – Section 382.309
Follow-up – Section 382.311



A driver who tests positive for a controlled substance(s) and/or alcohol test, will be immediately removed from a safetysensitive position as required by Part 382 of the FMCSR. Federal law prohibits a driver from returning to a safetysensitive position for any motor carrier until and unless the driver completes the Substance Abuse Professionals (SAP) evaluation, referral and educational/treatment process, as described in FMCSR Part 40, Subpart O.


The following is a referral list of Substance Abuse Professionals:

Patrick Panos
1192 Draper Parkway #225
Draper, UT 84020
801-671-5226

Marlin Andrus
2100 S. State Street
Salt Lake City, UT 84190
801-253-3169

Julio Landero
730 N. Eastern Suite 130
Las Vegas, NV 89101
702-768-2275


I have read the above controlled substances and alcohol testing requirements and understand them. I acknowledge receipt of the referral list of Substance Abuse Professionals.


Applicant Signature
Date
Letter Of Permission To Run Motor Vehicle Record

I give permission to Paul Terry Trucking Company, Inc. to run my Motor Vehicle Record (MVR). The details on my MVR will be held in the strictest of confidence and will be kept in my personnel file. This letter of permission is valid as long as I am an employee of Paul Terry Trucking Company, Inc.

Drivers License Number
Name as Appears on Drivers License
Expiration Date
Date of Birth
State of Issue
Social Security Number
Applicant Signature
Date
Important Disclosure Regarding Background Reports from the PSP Online Service

In connection with your application for employment with Paul Terry Trucking Company, Inc., Paul Terry Trucking Company, Inc., its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report.

State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.



If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize Paul Terry Trucking Company, Inc. to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.



Applicant Signature
Date