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Special Service Transportation Pre-Employment Application

* Indicates a required field

Personal Information

First Name:* Last Name:*

Date of Birth:* / / Social Security #:*

Address:*

City:* State:*

Zip Code:*

Contact Information

Phone:* E-mail Address:

Best Time to Call:*

Driving History

Have you attended a professional driver training school?

School Name: When?

US Military Service: Type of discharge:

Presently a member of the National Guard or Reserves?

Currently I Am:* Owner Operator Company Driver

Years of Experience:*

Commercial Driver License No.:*

State Issued:* Exp. Date:* / /

Class:* A B C

Endorsements: Hazmat Tanker Double/Triple

Driving Experience: Van Reefer Flatbed
Hazmat Tanker Double/Triple

List all motor vehicle accidents in which you were involved during the past five (5) years, regardless of fault, specifying the date and nature of each accident and any fatalities or personal injuries involved.

Date: Nature of Accident:

Location: Injuries or Fatalities:

List all violations of motor vehicles laws or ordinances (other than parking) of which you were convicted or forfeited bond during the past five (5) years.

Date: Type of Violation:

Place where Violation Occurred:

*Have you ever been denied the issuance of a license to operate a motor vehicle, or have you ever had a license to drive a motor vehicle revoked or suspended?

If you have answered "Yes". explain in detail the facts and circumstances.

*How many chargeable and non-chargeable accidents in the last 3 years?

Employment Information

Present Employer

Fill out this section only if currently employed as a professional driver.

Start:             /    /

Company:                                                       Phone:

Address:

City:                                                                     State:

Zip Code:

Previous Employer #1

Start:                 /    /              End :             /    /

Company:                                                       Phone:

Address:

City:                                                                     State:

Zip Code:

Previous Employer #2

Zip Code:

Previous Employer #3

Zip Code:

Criminal Record Information - If Any

*Have you ever been convicted of a felony? No Yes Date:

*Have you ever been convicted, or have No Yes Date:
any charges pending, for driving while under
the influence of alcohol, a narcotic
drug, amphetamines or derivatives thereof?

*Have you ever been denied a license, permit No Yes Date:

or privilege to operate a motor vehicle?

*Has any license, permit or privilege ever No Yes Date:
been suspended or revoked?

*Have you ever been convicted, or are any No Yes Date:
charges pending, for reckless or careless
operation of a motor vehicle?

*Have you ever been convicted, or are any No Yes Date:
charges pending, for possession, sale or use of
a narcotic drug, amphetamines, or derivatives
thereof?

*Have you ever been refused any type of No Yes Date:
insurance or been denied bonding?

*Have you ever been discharged or suspended? No Yes Date:

Comments

DAC Release

By submitting this application I certify that I personally completed this application and that all of the information is true and correct. I hereby request and authorize Special Service Transportation and their agents or contractors that receive this application to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I have completed this application of my own free will and hold harmless of all liability all companies, agents and associated parties for the use of this application. As part of our consideration of your application, the DOT requires companies to investigate your employment background. As part of this investigation, they may obtain consumer reports about you from DAC Services. DAC is a consumer reporting agency. Any decision they make not to hire you based on information contained in your consumer report will be their decision alone. DAC does not make any decisions concerning your employment with these companies and will not know the specific reasons why they may decide not to hire you. In the event you are not hired based on information contained in your consumer report, the companies them selves will tell you. We will also advise you of your right to obtain a free copy of the consumer report from DAC and your right to dispute the accuracy or completeness of your report. Your consent for these companies to obtain the report from DAC is required. Although you have a right to withhold your consent, companies will not consider your application if you withhold your consent.

*I have read the above release and I give permission
to obtain consumer reports about me from DAC.