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  • Gateway RV Transport

    2425 E US 6 Albion IN 46701
  • Personal Information

  • Truck Information

    If you are not sure about the information on your truck mark not sure and put the year as 2020
  • Residence Address for the Past Three (3) Years

  • Education and Military

    Some description about this section
  • Drivers License Information

  • List ALL driver's licenses that you presently hold or have held in the past three (3) years.

  • Accidents

    List and explain in detail, giving date, location of all accidents (regardless of fault) that you have been involved in during the past five (5) years in any type of vehicle. FAILURE TO LIST ALL ACCIDENTS MAY RESULT IN YOUR DISQUALIFICATION. If you have not been involved in an accident in the last five (5) years write "None".
  • Make sure to include date, type of vehicle, whose fault, if there were any fatalities or inhuries and $ amount of damage.
  • Driving/ Work Experience

    Please include all dates, including unemployed time beginning with your most recent employer. List all employers for the previous ten years and any other appliacable experience
  • Company 1
  • Company 2
  • Company 3
  • Company 4
  • 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.
  • 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.
  • 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.
  • 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.