Step 1 of 11

MVR Authorization

In conjunction with my potential employment at Santa Fe Tow Service, Inc. I consent to the release of my Motor Vehicle Records (MVR) to the company. I understand the company will use these records in connection with matters of motor vehicle or driver safety that may be related to the position for which I am applying. I also consent to the review and evaluation of the MVR I have provided to the company and understand that release of the MVR does not necessarily mean I will be hired for driving, or any other position.
This consent is given in satisfaction of Public Law 18 USC 2721 et. Seq., "Federal Drivers Privacy Protection Act" , and is intended to constitute "written consent" as required by this Act.

E-Signature*

Full Name of the Applicant

Date*

MM slash DD slash YYYY

Today's Date*

MM slash DD slash YYYY

Your Name*

First Middle Initial Last

Email*

Social Security Number*

Date of Birth*

MM slash DD slash YYYY

Home Phone*

Cell Phone:*

Current Address*

Street Address Address Line 2 City State ZIP Code

Past 3 Years of Residency

Previous Address #1

Street Address Address Line 2 City State ZIP Code

Previous Address #2

Street Address Address Line 2 City State ZIP Code

Previous Address #3

Street Address Address Line 2 City State ZIP Code

Position & Availability

Hours / Shifts you are seeking:*

Select all that apply

Desired Position*

Are you currently employed?*

Yes

Terminal Location*

Lenexa, KS

Blue Springs, MO

Joplin, MO

Dallas, TX

Date You Can Start*

MM slash DD slash YYYY

Days Available*

Salary Desired*

Please indicate per year or per hour

How did you hear about Santa Fe Tow Service or this position you are applying for?*

Have you ever been convicted of any crime or are you a convicted felon?*

Yes

Are you Authorized to work in the United States?*

Yes

Are you 21 years of age or older?*

Yes

Do you have a CDL (Commercial Drivers License)?*

Yes

Education

High School*

High School Location*

Years Completed*

College

College Location

Years Completed

Vocational/Tech School

Vocational/Tech School Location

Years Completed

Military Service

Branch

Years Served

Skills / Qualifications

List Special Skills, Proficiencies, or Talents that you can bring to Santa Fe Tow service:

List Certifications, Licenses, or Qualifications you have:

List Special Training or Awards you have received:

Driving Experience

If no driving experience within the last 3 years...

Check Here

Class of Equipment*

Type of Equipment*

Straight Truck Dates Driven*

From To

Tractor & Semi Trailer Dates Driven*

From To

Tractor - 2 Trailers Dates Driven*

From To

Tractor - 3 Trailers Dates Driven*

From To

Motor Coach - School Bus (greater than 8 passengers) Dates Driven*

From To

Motor Coach - School Bus (greater than 158 passengers) Dates Driven*

From To

Other Vehicle Dates Driven*

From To

Accident History - 3 Years

If no accidents within the last 3 years...

Check Here

Accident record for past 3 years*

Date

Nature of Accident

Fatalities

Injuries

HAZMAT Spill

Traffic Convictions/Forfeitures - 3 years

If no traffic conviction and/or forfeitures within the last 3 years...

Check Here

Traffic conviction and forefeitures for the past 3 years (other than parking violations)*

Date Convicted

Location

Violation

State

Penalty

(Month and Year)

License Information

section 383.21 FMCRS states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license." I certify that I do not have more than motor vehicle Iicense, the information for which is listed below.

Drivers License Number*

State*

State

Expiration Date*

MM slash DD slash YYYY

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

Yes

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

Yes

Employment History for Driver Applicants

All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record).

You are required by The Department of Transportation to list the complete mailing address; street numbers and name, dty, state, and zip code.

Current or Last Employer*

Position Held*

Current or Last Employer Address

Street Address Address Line 2 City State ZIP Code

Dates Employed*

From To

Reason for Leaving*

Were you subject to the Federal Motor Carrier safety Regulations** while employed?*

Yes

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirement of 49 CFR Part 40?*

Yes

Second Last Employer

Second Last Employer Position Held

Second Last Employer Address

Street Address Address Line 2 City State ZIP Code

Second Last Employer Dates Employed

From To

Second Last Employer Reason for Leaving

Second Last Employer: Were you subject to the Federal Motor Carrier safety Regulations** while employed?

Yes

Second Last Employer: Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirement of 49 CFR Part 40?

Yes

Third Last Employer

Third Last Employer Position Held

Third Last Employer Address

Street Address Address Line 2 City State ZIP Code

Third Last Employer Dates Employed

From To

Third Last Employer Reason for Leaving

Third Last Employer: Were you subject to the Federal Motor Carrier safety Regulations** while employed?

Yes

Third Last Employer: Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirement of 49 CFR Part 40?

Yes

Note

* Any gaps in employment and/or unemployment must be explained.** The federal Motor Carrier safety Regulations apply to anyone operating a motor vehide on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weights or has a GVWR of 10,001 pounds 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.

Account for period between jobs:

Include dates (month/year) and reason

If you have any additionial work history please enter it below:

Include dates (month/year)

PI Optional Research Questions

The Predictive Index invites you to participate in a short, confidential, and voluntary survey. You will be asked demographic questions and/or research questions to help us deliver up-to-date science for people around the world.

Please note that your voluntary responses:

Will not affect your assessment results in any way.
Are used by The Predictive Index solely for research purposes.
Are confidential and will not be disclosed to any third party, including any potential or current employers.

Click Here to complete the Predictive Index Behavioral Assessment!

Authorization

Affidavit, Consent, and Release

Please read each statement carefully before signing

Pre-employment Policies

I have read and understood the pre-employment policies of Santa Fe Tow service.

Completeness Certification

I certify that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge.

Background Authorization

I authorize Santa Fe Tow Service to make such investigations and inquiries of my personal, employment, financial, or medical history, and other related matters as may be necessary for 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 employer, school, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interviews may result in discharge. I understand, also, that I am required to abide by all the rules and regulations of Santa Fe Tow Service.

Rules & Regulations

Rights 9 CFR 391.23(b) and (e)

I understand that information I provide regarding current and/or previous employers may be used, and those employers will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(b) 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 Santa Fe Tow service; and
• Have a rebuttal statement attached to the alleged erroneous information if the previous employer and I cannot agree on the accuracy of the information.

E-Signature*

First Middle Last

Date*

MM slash DD slash YYYY

CAPTCHA

Driver Application

MVR Authorization

Past 3 Years of Residency

Position & Availability

Education

Skills / Qualifications

Driving Experience

Accident History - 3 Years

Traffic Convictions/Forfeitures - 3 years

License Information

section 383.21 FMCRS states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license." I certify that I do not have more than motor vehicle Iicense, the information for which is listed below.

Employment History for Driver Applicants

Note

PI Optional Research Questions

Authorization

Affidavit, Consent, and Release

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