Application – Gateway RV Transportation LLC

Gateway RV Transport

2425 E US 6 Albion IN 46701

Personal Information

Name *

First

Middle

Last

Date of Birth *

Phone # *

Address *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Country *

Social Security Number *

Email Address *

Have you ever worked or applied here before? *

Yes No

Date *

Emergency Contact *

First

Last

Relationship *

Phone # *

How did you hear about us? If you were refered by a friend please put their name. *

Truck Information

If you are not sure about the information on your truck mark not sure and put the year as 2020

Which divison are you applying for? *

Singles Multiples

Make *

Model *
Model *

Year *
If other, What Model? *

Residence Address for the Past Three (3) Years

Have you lived at another Address in the last three (3) Years *

Past Address 1

Address Line 1

Address Line 2

City

State

Zip Code

Country

Have you lived at another Address in the last three (3) Years

Past Address 2

Address Line 1

Address Line 2

City

State

Zip Code

Country

Have you lived at another Address in the last three (3) Years

Past Address 3

Address Line 1

Address Line 2

City

State

Zip Code

Country

Do you have a CDL? *

Yes No

What Class?

Class A Class B Class C

Education and Military

Some description about this section

Highest Grade Completed

Last School Attended

Degrees & Honors Received

Have you attended truck-driving school? *

Yes No

Name of School

Graduation Date

School's Address

Address Line 1

City

State

Other Education

Have you served in the armed forces? *

Yes No

What branch?

Dates of service

Special Skills

Are you currently a member of the active reserves or National Guard? *

Yes No

Drivers License Information

Have you ever been convicted of DWI, DUI, OWI, Careless or Reckless Driving? *

Yes No
Date *
Has your license (any) or privilege to drive ever been suspended or revoked for ANY reason? *

Yes No
Date *

Have you ever been convicted of any misdemeanor other than a traffic violation? *

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

Yes No
Date *

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

Drivers License# *

State *

Expiration *

Have you held another license in the past three (3) years? *

Yes No

Drivers License #

State

Expiration

Have you held another license in the past three (3) years? *

Yes No

Drivers License#

State

Expiration

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.

Accident 1 *

Have you been involved in another accident? *

Yes No

Accident 2

Have you been involved in another accident?

Yes No

Accident 3

Have you been involved in another accident?

Yes No

Accident 4

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

Name of Company *
Start Date *
Position *
Accidents *

Phone # *
End Date *
Supervisor Name
Were you required to Comply with the FMCSR's *

Yes No

Address *
Reason for Leaving
Equipment Operated *
Were you required to Submit to Drug / Alcohol Testing *

Yes No

Have you worked at another company in the last 10 years? *

Yes No

Company 2

Name of Company *
Start Date *
Position *
Accidents *

Phone # *
End Date *
Supervisor Name
Were you required to Comply with the FMCSR's *

Yes No

Address *
Reason for Leaving
Equipment Operated *
Were you required to Submit to Drug / Alcohol Testing *

Yes No

Have you worked at another company in the last 10 years? *

Yes No

Company 3

Name of Company *
Start Date *
Position *
Accidents *

Phone # *
End Date *
Supervisor Name
Were you required to Comply with the FMCSR's *

Yes No

Address *
Reason for Leaving
Equipment Operated *
Were you required to Submit to Drug / Alcohol Testing *

Yes No

Have you worked at another company in the last 10 years?3 *

Yes No

Company 4

Name of Company *
Start Date *
Position *
Accidents *

Phone # *
End Date *
Supervisor Name
Were you required to Comply with the FMCSR's *

Yes No

Address *
Reason for Leaving
Equipment Operated *
Were you required to Submit to Drug / Alcohol Testing *

Yes No

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.

Have you tested positive or refused a test on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during tha past two years? *

Yes No

Have you ever tested positive or refused any drug or alcohol test during the past five years? *

Yes No

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.

Are you currently working for another motor carrier or non-motor carrier? *

Yes No

Do you intend to work for another motor carrier or non-motor carrier while working for this carrier? *

Yes No

Do you agree to notify this carrier if you intend to work for another motor carrier or non-motor carrier while working for this carrier? *

Yes No

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.

Digital Signature *

Date *