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Commercial Driver Employment Application

An Equal Opportunity Employer

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related injury.

It is the policy of Central Wyoming Transportation to require prospective employees to pay for the pre-employment drug test. The fee of $50.00 will be paid directly to Central Wyoming Transportation before the prospective employee is taken to the drug testing facility for the urine test. Central Wyoming Transportation is a division of BAILEY ENTERPRISES, INC.

After thirty (30) days of continuous employment at Central Wyoming Transportation you will be reimbursed $50.00 for the cost of the test.

If you are applying for a CDL position you must fill out a Commercial Driver Employment Application.

If you have any questions regarding this policy, please contact Human Resources (307) 857-6750.

Note: All Applicants Must Be 21 Years Of Age Or Older To Apply. Fmcsr §391.11(1)

(To be considered, you must answer all questions completely)

Applicant Information

Applicant's name

Phone number

Mobile phone

Physical address

Mailing address (if different)

City

State

Zip

Years at this address

List Your Place Of Residence For The Past 3 Years (Per Fmcsa 391.23)

Address

Years at this address

City

State

Zip

Address

Years at this address

City

State

Zip

Position

Position(s) applying for

Date available to start work

Do you have experience in this/related area? YesNo
If yes, give years experience and your specific qualification

Are you at least 21 years old? YesNo

Can you provide proof of age? YesNo

Date Of birth

Do you have a Commercial Driver's License? YesNo

If yes, what class/endorsements?

Do you have a hazmat endorsement? YesNo

Employment History

Note: DOT requires that employment for at least 3 years and any commercial driving experience for the past 10 years be shown. List complete mailing address, street number, city, state, and zip code. Please list employers in reverse order starting with the most recent. Note: You Must List All Employers! Fmcsa 391.23 (2).

Current Or Last Employer:

Name

Employed from

Address

City

State

Position

Salary

Supervisor

Phone

Reason for leaving

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 lbs. or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Where you subject to the FMCSRs while employed? YesNo
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? YesNo

Account for periods between jobs - include dates (month/year) and reason.

Second Last Employer:

Name

Employed from

Address

City

State

Position

Salary

Supervisor

Phone

Reason for leaving

Account for periods between jobs - include dates (month/year) and reason.

Safety

Accident record for past 3 years or more. If you have not had any accidents, type 'None' in the first row. (Required per FMCSA §391.23)

Date	Nature of accident (head on, rear end, upset, etc.)	Injuries	Fatalities

Traffic violations & forfeitures for the past 3 years (other than parking violations). If none, type 'None' in the first row. (Required Per FMCSA §391.23)

Date	Location	Charge	Penalty

Education

Last school attended

Area of study

Attended from (date)

Attended to (date)

Certification/degree

City

State

Zip

Experience and Qualifications

Drivers license(s)

State	License number	Type	Expiration

Driving experience

Class Of equipment	Type Of equip. (van, tank, flat, etc.)	From (date)	To (date)	Approx. # of miles (total)
Straight truck
Tractor & semi-trailer
Tractor two trailers
Motorcoach school bus
Other

List states operated in for the past five years
Show special courses or training that will help you as A driver
Which safe driving awards do you hold and from whom?

Other Experience & Qualifications

Show any trucking, transportation or other experience that may help in your work for this company
List courses and training other than shown elsewhere in this application
List special equipment or technical materials you can work with (other than those already shown)

Work Restrictions - Required For Commercial Drivers

Have you ever been convicted of a felony? YesNo
If yes, please explain in full
Have you ever been denied a license, permit or privilege to operate a motor vehicle? YesNo
If tes, please explain in full
Has any license, permit or privilege ever been suspeneded or revoked? YesNo
If yes, please explain in full
Have you ever tested positive on a pre-employment drug or alcohol test? YesNo
If yes, please explain in full
Have you ever refused to submit to a drug or alcohol test? YesNo
If yes, please explain in full

FMCSA §391.15 (C)(2)(i)(A)or(B)

Personal References (Other Than Relatives)

Reference 1

Name

Address

City

State

How are you acquainted

Phone

Mobile

Reference 2

Name

Address

City

State

How are you acquainted

Phone

Mobile

Reference 3

Name

Address

City

State

How are you acquainted

Phone

Mobile

In Case Of Emergency, Contact

Name

Address

Relationship

Phone

Mobile

Certification

(Read each statement and check if you agree)

I certify that answers given by me herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment, or oral interview as may be necessary in arriving at an employment decision.

I authorize you 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.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered beyond this time period should inquire as to whether or not applications are being accepted at that time.

At Will Employment

(Read each statement and check if you agree)

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "AT WILL" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "AT WILL" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may prevent my being hired, or if hired may subject me to immediate dismissal. I understand, also that I am required to abide by all rules and regulations of the employer.

Authorization to Obtain Consumer Reports

(Read statement and check if you agree)

The Fair Credit Reporting Act (FCRA) provides individuals with certain rights regarding consumer reports, and places certain obligations on employers who use consumer reports for employment related purposes. Consistent with the requirements of the FCRA, this notice is provided to you in order to inform you that Central Wyoming Transportation may, for employment-related purposes (e.g., evaluating you for initial employment, promotions, transfers, assigned duties, retention as an employee, etc.), obtain from a consumer reporting agency one or more consumer reports containing financial information, criminal record information, driving record information, and/or other relevant information about you.

By Checking This Box you certify that you have read and understood the above notice and specifically authorize Central Wyoming Transportation to obtain one or more consumer reports on you for employment-related purposes, as indicated above, and authorizes Central Wyoming Transportation to investigate information submitted in this employment application.

Central Wyoming Transportation Adheres To The Drug-Free Workplace Act Of 1988

(Read statement and check if you agree)

All Central Wyoming Transportation employees are subject to alcohol and/or drug testing which includes pre-employment, post accident, post injury, random, reasonable suspicion, return to duty, & follow-up testing.

After thirty (30) days of continuous employment at Central Wyoming Transportation you will be reimbursed $50.00 for the cost of the test.

Any adulteration of sample will be considered a refusal to test, which can result in disciplinary action up to and including termination.

By checking this box you certify that you have read and understood the above notice regarding the Drug-Free Workplace Act of 1988.

Use Of Previous Employer Information

(Read statement and check if you agree)

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 as required by 49 CFR3 391.23 (d) and (e). I understand that I have the right to:

Review information provided by current/previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

If you have any questions regarding this policy, please contact Human Resources at (307) 857-6750.

(Notice: you cannot submit this form until you agree to all items in the Certification, At Will Employment, Authorization to Obtain Consumer Reports, Drug-Free Workplace, and Use of Previous Employer Information sections.)