Mansur TRUCKING INC

Driver Application

Please answer all appropriate questions completely. All qualified applicant will receive consideration without
discrimination based on sex, sexual orientation, race, age, creed national origin or the presence of disabilities (unless
the disability limits your ability to perform the essential functions of the job). Additional job related testing for skills
may be required. Testing for the presence of illegal drugs may be required prior to employment. Certain positions
may require additional testing and medical review to determine job fitness.


Company Driver Application Form

Last Name: Today's Date:
First Name: Date of Birth : (MM/DD/YYYY)
Middle Initial: Phone: ( )
Position(s) Applied for Email:

Current and Two (2) Years Previous Addresses

Address 1: From: To: (MM/YYYY)
     City: State:      Zip:
Address 2: From: To: (MM/YYYY)
     City: State:      Zip:
Address 3: From: To: (MM/YYYY)
     City: State:      Zip:

Do you have the legal right to work in the United States?

Can you provide proof of your age?

Have you worked for this company before? Where?

Were you subject to FMCSR's?

Was job designed as a safety sensitive function in any DOT regulated mod to Drug and Alcohol testing as requied by 49CFR, part 40?
From: To: (MM/YYYY) Rate of Pay
Position       Reason for Leaving

Are you now employed?

If not, how long since leaving last employment?

Who Referred you? Rate of Pay expected

Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the standard job description]?
If Yes, explain if you wish

Employment

Give a Complete Record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past ten years.

Present or Last Employer:

Name:     From: To:
Address:  Position Held:
City:        Salary:
State:     Zip: Reason For Leaving:
Phone: ( ) Contact Person:
Were you subject to FMCSR's?
Was job designed as a safety sensitive function in any DOT regulated mod to Drug and Alcohol testing as requied by 49CFR, part 40?


Next Previous Employer:

Name:     From: To:
Address:  Position Held:
City:        Salary:
State:     Zip: Reason For Leaving:
Phone: ( ) Contact Person:
Were you subject to FMCSR's?
Was job designed as a safety sensitive function in any DOT regulated mod to Drug and Alcohol testing as requied by 49CFR, part 40?

Next Previous Employer:

Name:     From: To:
Address:  Position Held:
City:        Salary:
State:     Zip: Reason For Leaving:
Phone: ( ) Contact Person:
Were you subject to FMCSR's?
Was job designed as a safety sensitive function in any DOT regulated mod to Drug and Alcohol testing as requied by 49CFR, part 40?

Next Previous Employer:

Name:     From: To:
Address:  Position Held:
City:        Salary:
State:     Zip: Reason For Leaving:
Phone: ( ) Contact Person:
Were you subject to FMCSR's?
Was job designed as a safety sensitive function in any DOT regulated mod to Drug and Alcohol testing as requied by 49CFR, part 40?

Driving Experience

Class of Equipment
From
To
Approximate Number of Miles (Total)
Straight Truck
Tractor and Semi-trailer
Tractor - two trailers
Other:
List States Operated in for the last five (5) years.
Show Special Courses or Training that will help you as a driver

Accident Record for the past three (3) years

Dates
Nature of Accident
(Head on, rear end, upset,etc.)
# of Fatalities
# of People Injured
If more space needed, please use the space below:

Traffic Convictions and Forfeitures for the last three years

(other than parking violations)
Location
Date
Charge
Penalty
If more space needed, please use the space below:

Driver's License

(list each driver's license held in the past three years)
State
License Number
Type
Expiration Date
If more space needed, please use the space below:
 
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Yes        No
B. Has any license, permit, or privilege ever been suspended or revoked?  
Yes       No
If the answer to A or B is YES, give details:
 
 

Have you ever been convicted of a crime in the last 10 years?
Yes     No Felony Misdemeanor

If the answer to question is YES, give details:

Have you ever tested positive on, or refused, any pre-employment drug or alcohol test during the past two years?
Yes     No

Have you ever been convicted of a DUI or other alcohol or drug related offense in the last 10 years?
Yes     No


Education

Select Highest grade completed
High School
1    2    3    4
College
1    2    3    4
Last School Attended:

To Be Read and Signed by Applicant

This Certifies 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.

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, inquires 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.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

Date:              Applicants Name: (acts as signature)

Please fill out this form and include it as an email attachment to application@mansurtrucking.com: PSP Form