Company Driver Application Survey

R.L. Carter Trucking, Inc.
8451 S. State Road 39
Clayton, IN 46118

Phone: 317.539.4364 or 1.800.531.7124
Fax: 866.560.3446

In Compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex, national origin, age, marital status, or non-job related disability.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e).

I also understand that I have the right to:
* Review information provided by previous employers
* Have Errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer, and
* Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I also understand that I have the right to: * Review information provided by previous employers * Have Errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer, and * Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information. I agree and understand

Driver Name (Last),(First),(Middle):

Date of Birth

	Month	Day	Year
D.O.B:	Date of Birth D.O.B: Month	Day	Year

Social Security Number (no dashes or spaces):

Address

Address Street Address:
City:
State:
Zip:
Telephone Number (with area code):

EMERGENCY CONTACT

EMERGENCY CONTACT Name:
Phone #:

Email Address:

GENERAL

	YES:	NO:
Have you ever been convicted for DUI, DWI or OUI?:	GENERAL Have you ever been convicted for DUI, DWI or OUI?: YES:	Have you ever been convicted for DUI, DWI or OUI?: NO:
Is there any reason you might be unable to perform the functions of the job for which you have applied?:	Is there any reason you might be unable to perform the functions of the job for which you have applied?: YES:	Is there any reason you might be unable to perform the functions of the job for which you have applied?: NO:
Have you been a driver for this company before?:	Have you been a driver for this company before?: YES:	Have you been a driver for this company before?: NO:

If yes, when?

EDUCATION

	Elementary/HS	College
Please select the highest grade completed:	EDUCATION Please select the highest grade completed: Elementary/HS	College

Other Training:

Have you received any safety awards or special training?:

Have you received any safety awards or special training?: Yes:

No:

If yes, please explain

Do you have full knowledge of the Federal Motor Carrier Safety Regulations?

Do you have full knowledge of the Federal Motor Carrier Safety Regulations? YES:

NO:

Previous Addresses for the Past Three(3) Years(if applicable).

Previous Addresses for the Past Three(3) Years(if applicable). 1) Street Address:
City:
State:
Zip:
From:
To:
2) Street Address:
City:
State:
Zip:
From:
To:
3) Street Address:
City:
State:
Zip:
From:
To:

Company Driver Application

1. Driver Information