RMX Driver Application

We do not discriminate on the basis of race, color, religion, national origin, sex, age, or non-job related disability. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job related factors.

NOTE: Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information.

APPLICATION FOR EMPLOYMENT

APPLICATION MUST BE RENEWED AFTER 90 DAYS

Name*

First Middle Last

Date:*

Date of Birth:*

The Federal Motor Carrier Safety Regulations require that driver applicants state their date of birth (§391.21 (b)(2))

Address:

*If at the below residence for less than three years. List below all residences for the past three years by clicking the plus sign.

Street Address City State ZIP Code

Phone:*

Cell Phone:

Email Address:*

Position Applying for:*

Type of Position:*

Casual
Part Time
Full Time

How did you hear about our company?*

Who referred you?

Rate of pay expected?*

Any relatives employed by this company?

List Relative Name(s)

Have you worked for this company before?

Yes
No

Start and End Dates Previously Employed:

Where?

Currently employed?*

Yes
No

How long since last employment?

What date are you available to start work?*

Are you eligible to work in the U.S.?*

Yes
No

Education

Highest Grade Completed in Grade School:*

Years of College Completed (If Applicable):

Name and Address of Last School Attended:*

General

Have you ever been convicted of a felony?*

Yes
No

If yes, please explain fully below. Conviction of crime is not an automatic bar to employment – all circumstances will be considered.

Have you ever been known by any other name?*

Yes
No

If so, under what name?

DRIVING EXPERIENCE AND QUALIFICATION

Drivers Licenses held in the past three years must be shown. If none, leave blank. To add additional licenses click the plus button below.

Licenses

State:

License Number:

Class:

A
B
C
Other

Please list other Classes here:

Endorsements:

(Check those that you have now)

Hazardous
Tank
Doubles/Triples
Passenger
Air Brake

Epiration Date:

~IMPORTANT: APPLICANT MUST READ AND ANSWER THE FOLLOWING QUESTIONS~

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

Yes
No

Explain here.

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

Yes
No

Explain here.

Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?*

Yes
No

Explain here.

Have you ever refused any drug or alcohol test or tested positive for same within the last three years?*

Yes
No

List the company name, telephone # and date(s):

Driving Experience

Straight Truck:

Type of Equipment	Start Date	End Date	Approximate Total Miles

Tractor/Semi-Trailer:

Type of Equipment	Start Date	End Date	Approximate Total Miles

Tractor/Semi-Trailer:

Type of Equipment	Start Date	End Date	Approximate Total Miles

Twin Trailer-LVC’s:

Type of Equipment	Start Date	End Date	Approximate Total Miles

Other:

Type of Equipment	Start Date	End Date	Approximate Total Miles

List states operated in during last five years:

List special courses or training that will help you as a driver (include any T-T driving schools):

List driving awards held and who awards were presented by:

Accident Review for Past 5 Years. If none, leave blank:

(Head-on, rear-end, overturn, etc.)

Date	Nature of Accident	Fatalities	Injuries

Traffic Convictions and Forfeitures for the past 3 years other than parking violations. If none, leave blank:

Location	Date	Charge	Penalty

Employment Record

List all employers (not just driving jobs) for last ten (10) years. Start with current position, including military experience, and work back. If unemployed more than 1 month, list as separate item as “unemployed.” Gaps in employment must be explained.

Employment Details

Company Name:

Supervisor’s Name

Street Address:

City/State:

Phone:

Start Date:

End Date:

Salary:

Position Held:

Reason for leaving:

Were you subject to the Federal Motor Carrier Safety Regulations 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

APPLICANT MUST READ AND SIGN

I certify that I have read and understand all of the employment application. Further, that I completed this application and that all of the information I supply in this application packet is a full and complete statement of facts and contains no material omissions. It is understood that if any falsification is discovered, it will constitute grounds for rejection of application for employment or, if hired, dismissal from employment upon discovery thereof. If hired, I agree to abide by all the rules and policies of the employer.

I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks that are pertinent to the job. I also understand that if offered a job, the offer may be conditioned on the results of a physical examination and drug/alcohol tests.

In addition, I authorize, RMX, to obtain the necessary hospital reports and other documents that would indicate whether there were any controlled substances in my system if I am seriously injured while on-the-job and cannot provide a specimen at the time. The authorization conforms with Section 391.113(B) of the Federal Motor Carrier Safety Regulations. I understand that prior to any hiring decision-that I have the following rights regarding the investigative information that will be provided to employer pursuant to 49 CFR 391.23(d) and (e):

The right to review information provided by current/previous employers;
The right to have errors in the information corrected by previous employers and for that previous employer to re-send the corrected information to the prospective employer;
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.

I also understand that this application is not a contract of employment. I understand that if I am employed I will be an at-will employee and I may voluntarily leave my employment or my employment may be terminated at any time for any reason. I acknowledge that no written or oral statements have been made to or relied upon by me regarding the length of employment or the reasons for which my employment can be terminated.

Applicant Initials:*

(Applicant initials serve as applicant’s electronic signature)

Date:*

Next Day LTL Service — Since 1917