Paul Transportation, Inc.
PO Box 5006
Enid, OK 73702
Recruiting: 866-934-7285 |
| GENERAL INFORMATION |
| Company Or Owner? |
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| First Name: |
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Last Name: |
| Current Address: |
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| If different, mailing address: |
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Do you have the right to legally remain and work in the US? |
| DOB: |
Are you 23 years of age or older? |
| Have you worked here before? If so, in what capacity? |
| How did you hear of us?: |
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| When would you be available to start? |
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| DRIVING RECORD |
| License Information (Past 3 Years) |
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| Have you had any preventable accidents in the past 12 months? |
| EMERGENCY CONTACT INFORMATION |
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| Relation to applicant: |
| PREVIOUS EMPLOYMENT (10 YEARS) |
| Most recent job |
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| Presently employed? If so, may we call your present employer? |
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| Subject to FMCSRs? |
Why did you leave? |
| Subject to DOT regulated controlled substance and alcohol testing (49 CFR part 40)? |
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| Subject to DOT regulated controlled substance and alcohol testing (49 CFR part 40)? |
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| Subject to FMCSRs? |
Why did you leave? |
| Subject to DOT regulated controlled substance and alcohol testing (49 CFR part 40)? |
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| Fourth Recent Job |
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| Subject to FMCSRs? |
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| Subject to DOT regulated controlled substance and alcohol testing (49 CFR part 40)? |
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| Fifth Recent Job |
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| Subject to FMCSRs? |
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| Subject to DOT regulated controlled substance and alcohol testing (49 CFR part 40)? |
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| Sixth Recent Job |
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| Subject to FMCSRs? |
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| Subject to DOT regulated controlled substance and alcohol testing (49 CFR part 40)? |
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| Seventh Recent Job |
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| Subject to FMCSRs? |
Why did you leave? |
| Subject to DOT regulated controlled substance and alcohol testing (49 CFR part 40)? |
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| Eighth Recent Job |
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| Subject to FMCSRs? |
Why did you leave? |
| Subject to DOT regulated controlled substance and alcohol testing (49 CFR part 40)? |
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| Ninth Recent Job |
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| Subject to FMCSRs? |
Why did you leave? |
| Subject to DOT regulated controlled substance and alcohol testing (49 CFR part 40)? |
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| Tenth Recent Job |
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| Subject to FMCSRs? |
Why did you leave? |
| Subject to DOT regulated controlled substance and alcohol testing (49 CFR part 40)? |
| EXPERIENCE |
| OTR Years: |
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| Flatbed Years: |
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Commodities: |
| Coil Years: |
| Do you have a TWIC card? |
Expiration? |
| Oversize Experience? |
| What have you hauled? |
| Have you ever been denied a license, permit, or privilege to operate a motor vehicle? |
| Have you ever had any license, permit, or privilege suspended or revoked? |
| Have you ever been convicted for driving while under the influence of alcohol or drugs? |
Have you ever been refused liability insurance? |
Have you ever been convicted of a crime? |
Have you ever been disqualified to drive by Federal Regulations? |
Have you ever been refused a security bond? |
Have you ever tested positive, or refused a pre-employment DOT test, within the past 2 years? |
| ACCIDENT RECORD (PAST 3 YEARS) |
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| CONVICTIONS (PAST 3 YEARS) |
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| DISCLOSURE AND RELEASE |
In connection with my application for employment (including contract for services) with Paul Transportation, Inc., I understand that investigative consumer reports are being requested from USIS/DAC Services, Tulsa, Oklahoma. These reports may include information as to my character, work habits, performance and experience, along with reasons for termination of past employment from previous employers, accidents, DOT related drug and alcohol information. Further, I understand that you will be requesting information that may contain public record information from various federal, state, and other agencies which maintain records concerning driving record, workers compensation claims, credit, bankruptcy proceedings, criminal records; as well as information from USIS/DAC concerning (1) previous driving record requests made by others from such state agencies; (2) state provided driving records; (3) claims involving me in the files of insurance companies.
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY USIS/DAC SERVICES OR PAUL TRANSPORATION, INC. TO FURNISH THE ABOVE-MENTIONED INFORMATION.
I have a right to make a written request to USIS/DAC, 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 source of information; and the recipients of any reports on me which USIS/DAC Services has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from USIS/DAC Services and I agree that the information which USIS/DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies which subscribe to USIS/DAC Services.
I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports and anytime my employment (or contract) period.
I also understand that under the Federal Motor Carrier Safety Regulations, Paul Transportation, Inc. will release my employment information pertaining to controlled substance and alcohol testing records or failure thereof for the past three years, accident information for the past three years, work performance, dates of hire and termination and reason or termination to commercial motor carriers upon written request and my authorization to do so. I also understand and agree that the release of this information may be done through USIS/DAC services.
FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
I understand that in accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91 508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104 208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations.
DUE PROCESS RIGHTS FEDERAL MOTOR CARRIERS SAFETY REGULATIONS 391.23 (I)
I am acknowledging that Paul Transportation, Inc has expressly notified me that Department of Transportation regulated employment during the preceding three years via the application form or other written documentation prior to the hiring decision that I have the right to review such information provided by previous employers. I have also been informed that I have the right to have errors in the information corrected by the previous employer and for that previous employer to re send the corrected information to Paul Transportation, Inc. with my right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the myself cannot agree on the accuracy of the information.
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| SIGNATURE |
My signature below 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 understand that intentional falsification of this application may result in disqualification from employment consideration or termination of employment.
NOTE: Online applications cannot be reviewed or processed without a signed release from the applicant. Please print this form and fax to 405-440-2390 or call 866-934-7285 with a fax #.
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| Printed Name: |
| Date Signed: |
| Published: 10/19/09 |
