Driver Application - Jones Brothers Trucking · HireRight, Inc., or another consumer reporting agency, will obtain the reports for the Company. Hire right, Inc., is located at 5151

Driver Application

Date: _______________________________

Date of Birth: _________________________ *The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age withrespect to individuals who are at least 40 years of age.

Full Name: ___________________________________________________________________

Social Security #: _______________________________

Current Address:

____________________________________________________________________________ Street Address

____________________________________________________________________________ City State Zip Code

Phone #: ___________________________ Email: ______________________________

P.O. Box 4414 Missoula, MT 59806

Ph: (406) 721-0897 - (Tom: Ext. 233 - Rex: Ext. 235) Toll free: (800) 877-1075 Fax: (406) 721-0687

E-mail: [email protected] or [email protected]

In compliance with federal and state equal employment laws, qualified applicants are considered for all positions without regard to Race, Color, Religion, Sex,

National Origin, Age, Marital Status, or Non-Related Disability.

We operate in all 48 states.

We are an E-Verification employer. You can learn more about E-Verification at: www.dhs.gov/E-Verify

Current Contact Information

UPDATED: 7/19/2016 Page 1 of 14

Addresses for the past 3 years and how long resided:

____________________________________________________________________________

Do you have legal right to work in the US?

___________ (Yes/No)

Do you currently have a US Passport or US Passport Card? (If you have any DUI’s that are less than 10 years old, or have ever been arrested (even if it was 30 years ago) please contact us to see if it’s something we can help get you cleared.)

___________ (Yes/No)

Are you currently employed?

___________ (Yes/No)

If not, how long have you been unemployed?

____________________________________

Position applied for:

____________________________________

Who/what referred you?

____________________________________

DOT Physical Expiration Date:

____________________________________

When would you be available to start work?

____________________________________

Are there any combinations of vehicles you will not operate?

____________________________________________________________________________


Emergency Contact Information (In case of an emergency, who should we contact?)

Full Name: ___________________________________________________________________

Relationship: _______________________________

Address:

____________________________________________________________________________ Street Address


Phone #: ___________________________

Driver Job Description

• 21-25 Days away from home• Drive up to 11 hours a day• Travel US• Lift 50 lbs. to waist• Climb up/down on trailer• Must pass a DOT physical• Must pass DOT drug/alcohol test• Have no DUI’s in past 3 years

• Have basic reading/writing/math skills• Professional attitude/appearance• Comply with DOT regulations• Tarp/un-tarp loads• Climb up/down ladders to secure

loads (12'+)• Have a valid class A CDL• List driving record for past 3 years

Are there any reason(s) why you might not be able to perform the functions of the job for which you have applied, from the items listed? (List any accommodations if needed.) *The Federal Motor Carrier Safety Regulations (FMCSR's) apply to anyone who operates a motor vehicleon a highway in interstate commerce to transport passengers or property when the vehicle (1) has aGVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers,or (3) is of any size used to transport hazardous materials in a quantity requiring placarding.

____________________________________________________________________________


Employment History All applicants desiring to operate in interstate commerce must provide the following information on all employers (transport & non-transport) during the past or preceding 3 years. Not to disclose all employment for any reason is a direct violation of 391 of the Federal Motor Carrier Safety Regulations (FMCSR), and can be cause for immediate termination.

Applicants driving a commercial motor vehicle in interstate or intrastate commerce shall also provide employment for an additional 7 years. Example: If you have driven for the past 15 years, you must list each employer for the past 10 years. Do the best you can. Please answer all questions, do not leave any blanks, if your answer to a question is none, then write NONE, if something is not applicable then write N/A.

Starting Date: _________________________ Ending Date: _________________________

Company Name: ___________________________ Position: __________________________

City/State: ___________________________ Phone #: ___________________________

Reason for Leaving: ___________________________________________________________

May we contact your current employer?

___________ (Yes/No)

Were you subject to the FMCSRs* while employed here?

___________ (Yes/No)

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

___________ (Yes/No)



City/State: ___________________________ Phone #: ___________________________



___________ (Yes/No)


___________ (Yes/No)




City/State: ___________________________ Phone #: ___________________________



___________ (Yes/No)


___________ (Yes/No)



City/State: ___________________________ Phone #: ___________________________



___________ (Yes/No)


___________ (Yes/No)



City/State: ___________________________ Phone #: ___________________________



___________ (Yes/No)


___________ (Yes/No)


Personal References List three personal references other than family members:

Full Name: ___________________________________________________________________

Current Address:

____________________________________________________________________________ Street Address


Phone #: ___________________________ Email: ______________________________

Full Name: ___________________________________________________________________

Current Address:

____________________________________________________________________________ Street Address


Phone #: ___________________________ Email: ______________________________

Full Name: ___________________________________________________________________

Current Address:

____________________________________________________________________________ Street Address


Phone #: ___________________________ Email: ______________________________


Current Driver’s License Information

State: ____________________________ License Type: ______________________________

License #: ___________________________ Expiration: ______________________________





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

___________ (Yes/No)

Have any license, permit, or privilege ever been suspended or revoked?

___________ (Yes/No)

If you answered yes to any of the previous two questions, please explain:

____________________________________________________________________________

Please provide the information as listed on your current driver’s license. (If you have a Washington Driver’s License (or have had one within the last 3 years), please complete a WA MVR Request form and email it to [email protected] or [email protected]) The form is available here: https://www.jonesbrotherstrucking.com/washington-mvr-release-of-interest/

Date of Birth: _________________________

Full Name: ___________________________________________________________________

Address:

____________________________________________________________________________ Street Address



License Type: ________________________

Driver’s License Information for the Last 3 Years


Driving Experience Please list all driving experience in relation to Straight Truck, Tractor Trailer, Doubles, etc. List the type of equipment used, dates, and approximate number of miles.

____________________________________________________________________________

Number of states traveled: ____________

Accident Record Please list all accidents within the last 3 years in any motor vehicle (other than parking tickets.) Include the date, nature of the accident, and if there were any injuries/fatalities.

____________________________________________________________________________

Traffic Convictions List all traffic convictions within the past three years, including the locations, dates, charges and penalties.

____________________________________________________________________________


Education

Highest Grade Completed: ______________________________________________________ If you attended college, list ‘College’ followed by number of years completed.

Last School Attended: __________________________________________________________

Truck Driver Training School/Location: _____________________________________________

Experience and Qualifications List any trucking, transportation, or other experience that may help in your work for this company.

____________________________________________________________________________

List courses and training other than shown elsewhere in this application. If you graduated from a truck driving school, please list the school name along with the date of graduation.

____________________________________________________________________________

TO BE READ AND SIGNED BY APPLICANT

This certifies that I have completed this application and that all entries and information in it are true and complete to the best of my knowledge.

I authorize Jones Brothers Trucking 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, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.)

I hereby release employers, schools, healthcare 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 and federal laws. Employment begins after satisfactorily completing Jones Brothers Trucking orientation/training.

___________________________________________________ _________________ Applicant’s Signature Date


Disclosure and Authorization [Jones Brothers Trucking], (the "Company") may request background information about you from a consumer reporting agency in connection with your employment application and for employment purposes. This information may be obtained in the form of consumer reports and/or investigative consumer reports. These reports may be obtained at any time after receipt of your authorization and, if you are hired by the Company, throughout your employment.

HireRight, Inc., or another consumer reporting agency, will obtain the reports for the Company. Hire right, Inc., is located at 5151 California Avenue, Irvine, CA 92617, and can be contacted at 800-490-7983. The reports may contain information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The types of information that may be obtained include, but are not limited to: social security number verifications; credit reports; criminal records checks; public court records checks; driving records checks; educational records checks; employment verifications; personal and professional references checks; licensing and certification records checks; drug testing results; etc. The information contained in the reports will be obtained from private and public record sources, including, as appropriate, personal interviews with sources, such as neighbors, friends and associates.

You may request more information about the nature and scope of any investigative consumer reports by contacting the Company at: Jones Brothers Trucking, 7145 Hwy 10 West, Missoula, MT 59808. A summary of your rights under the Fair Credit Reporting Act is also being provided to you.

Additional State Law Notices

If you are a Washington applicant, please also note:

WASHINGTON STATE: If we request an investigative consumer report, you have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from us a complete and accurate disclosure of the nature and scope of the investigation we requested. You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

AUTHORIZATION

I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to the release of consumer reports and investigative consumer reports prepared by a consumer reporting agency, such as HireRight, Inc., to the Company and its designated representatives and agents. I understand that if the Company hires me, my consent will apply, and the Company may obtain reports, throughout my employment.

I also understand that information contained in my job application or otherwise disclosed by me before or during my employment, if any, may be used for the purpose of obtaining consumer reports and/or investigative consumer reports.

By my signature below, I authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency.

By my signature below, I certify the information I provided on this form is true and correct. I agree that this Disclosure and Authorization form in original, faxed, photocopied or electronically (including electronically signed) form; will be valid for any reports that may be requested by or on behalf of the Company.

California, Minnesota or Oklahoma applicants only - You will be provided with a free copy of any consumer reports or investigative consumer reports obtained on you if you check the box below:

Applicant’s Full Name: __________________________________________________________________________

Social Security #*: _______________________________ Date of Birth: ___________________________________

Current Address:

_____________________________________________________________________________________________ Street Address

_____________________________________________________________________________________________ City State Zip Code

Addresses:

Driver’s License #: ______________________________________

___________________________________________________ ____________________ Applicant’s Signature Date

*This information will be used only for background screening purposes and will not be taken in to consideration in any employment decisions.


Essential Job Functions – Commercial Truck Driver – Class A The following are physical requirements pertaining to the job(s) for which you are applying. These bona fide physical requirements are essential functions of the job and are in addition to the skill, certification, years of experience and other qualifications required to perform the job(s) for which you have applied.

Please be aware that all persons may be required to furnish health condition information and if necessary, submit to an examination by a company-designated physician. This information will be used to determine appropriate job placement. It shall not be used to disqualify an otherwise qualified person who may have a mental or physical disability.

These statements/questions pertain only to the essential functions of the job for which you are applying.

Can you sit and drive as required for an 11-hour shift?

___________ (Yes/No)

Can you perform repetitive motion tasks with your hands and wrists?

___________ (Yes/No)

Can you push and pull levers or objects that require 50lbs. of force or more?

___________ (Yes/No)

Do you have free and continual movement of your legs and feet as required to safely operate a clutch, brake and gas pedal or foot controls of a truck?

___________ (Yes/No)

Can you climb stairs and/or a ladder to safely get in and out of a truck, or to climb up and down from a load or trailer regularly?

___________ (Yes/No)

Can you grip, grasp and twist using your hands and wrists constantly as is required to safely operate the steering, shifting, or other mechanical or hydraulic controls of a truck?

___________ (Yes/No)

If required, are you able to lift up to 50 lbs. to your waist?

___________ (Yes/No)

If you answered NO to any of the above questions, please explain below.

________________________________________________________________________________________________________

I understand that any misstatement, omission, falsification, or misrepresentation of fact on this form is grounds for withdrawal of the conditional job offer, or termination of employment if already employed.

___________________________________________________ __________________________ Applicant’s Signature Date

___________________________________________________ __________________________ Name (Please Print) Social Security #


THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BYALL ACCOUNT HOLDERS

IMPORTANT DISCLOSUREREGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Jones Brothers Trucking (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Jones Brothers Trucking (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

__________________________ Date

___________________________________________________ Applicant’s Signature

___________________________________________________ Name (Please Print)


Attn: ________________________________ From: Rex/Tom – Jones Brothers Trucking

Fax #: _______________________________ Return to Fax #: (406) 721-0687

REQUEST FOR DRIVER'S SAFETY PERFORMANCE HISTORY & DRUG AND ALCOHOL TESTING INFORMATION

Jones Brothers Trucking - 7145 Hwy 10 W - Missoula, MT 59808 406-721-0897 Ext. 235 - Rex or Ext. 233 Tom * Toll free 800-877-1075 * Fax 406-721-0687

Name: _______________________________________ SS#: _________________________ DOB_______________

I hereby authorize this Company to release all records of employment, including assessments of my job performance, ability and fitness, (including results of any and all alcohol or drug tests, dates of any confirmed positive results, and/or my refusal to submit to any alcohol or drug tests and any rehabilitation completed under the direction of a SAP/MRO. I hereby release this company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company.

___________________________________________________ __________________________ Applicant’s Signature Date

APPLICANT IS TO FILL OUT BETWEEN THE LINES ONLY - DO NOT WRITE BELOW THIS LINE

-TO BE COMPLETED BY PREVIOUS EMPLOYER-Dates of employment: _________To_________ Drivers/Employee's Function: ______________________________ If driver, type of vehicles driven: flatbed, dry-van, hopper, end-dump, lowboy, tanker, bulk, livestock, belly-dump, doubles, straight truck, refer, car/pickup, other: _____________________ If driver, area of operation: Local, 48 states, regional, other: ________________________________ Was Employee Full/Part Time?________________ Was Employee's work performance: Poor, Good, Above Average, or Excellent? ______________________________ Did Employee follow Company Policy? Yes/No If not please explain: ______________________________________ ______________________________________________________________________________________________ Reason for leaving: ______________________________________________________ Eligible for Rehire? Yes/No Convicted of any Traffic violations: Yes/No License Suspended, revoked, or denied: Yes/No

Accident/Claim History

Date Nature of Accident Fatalities/Injuries Preventable/Non-Preventable DOT

Additional Comments: _____________________________________________________________________________

DRUG/ALCOHOL INFORMATION Drug and Alcohol information required by FMCSR Part 391.23/40.25

Has the above driver had a .04 or more alcohol test, verified positive drug test, refusals to be tested, or any other drug and alcohol violations? Please list date(s) and explain: _____________________________________________ ______________________________________________________________________________________________ If this driver successfully completed a SAP rehabilitation referral and remained in your employ, did he/she have any subsequent violations for the above listed infractions? Yes/No Explain: _____________________________________ ______________________________________________________________________________________________ If yes to any of the above questions, please provide documentation of successful completion of a SAP evaluation, prescribed treatment and return-to-duty requirements (including follow-up tests) if they remained in your employ.

Previous Employer Representative Supplying Information, please sign below: Signature: ___________________________________________ Title: ____________________________________ Print Name: __________________________________________ Date: ____________________________________

Previous Employer: ________________________________________ Contact: ____________________________City, State, and Zip: ____________________________________________________________________________Phone Number: __________________________________ Fax Number: __________________________________Employees Function: ________________________________ Dates of Employment: ___________ to ___________


Pay and Benefits Package

• $500.00 Bonus for recent CDL school grads.• $1,000.00 Bonus for drivers with 1 year recent O.T.R. Experience.• $2,000.00 Bonus for drivers with recent 3 years or more O.T.R. Experience.

Full CDL school training is also available! • All trainees are paid minimum wage during training.• Training program is 4 to 5 weeks, Monday – Friday.• The full course is 300+ hours of classroom and hands on over the road training

involving loading and tarping loads throughout western Montana and Idaho.

Driver Pay • Base mileage pay is DOE • 14 to 21 days out; very flexible home time• 1,400 mile average haul• $100.00 crossing pay in to Canada• Achievable fuel bonus program (base mpg 6.0) we split 50% of overall savings with you!• Paid practical route miles (loaded and unloaded)• Additional pay for over dimensional loads• Weekly pay• $50.00 tarp pay ($25.00 on/off)

Short Haul Bonus Pay • 401 – 500 miles – additional $0.15 per loaded mile• 301 – 400 miles – additional $0.20 per loaded mile• 300 miles or less – additional $0.25 per loaded mile

Per Diem • $0.15 per mile – (per diem is a reimbursement which the driver does not pay

taxes on, therefore, increasing net pay.

Health Insurance • Full premium is paid by Jones Brothers for the employee. We pay 40% of

premium for spouse/dependent coverage.• Full vision premium is paid by Jones Brothers for employee and any

dependents.• HRA reimbursement account paid by Jones Brothers to reduce out of pocket

health expenses.• $500.00 flex account provided by Jones Brothers for vision, dental,

prescriptions, co-pay, etc., tax free.• Up to $2,550.00 can additionally be withheld from your pay (tax free) to cover

medical expenses.

Simple IRA/Retirement Savings • Company matches dollar per dollar, up to 3%• Flexible home time, cell-phone reimbursement, family rider program• 2 national fuel cards, paid vacations, and small company/family atmosphere.

Please feel free to contact us with any questions.

Rex: (406) 552-5580 / Tom: (406) 360-2730

[email protected]

WWW.JONESBROTHERSTRUCKING.COM

• Progressive and extra drop pay: (1 - 4 = $25.00) (5 - 7 = $40.00) (8+ = $50.00)


Documents

Driver Application - Jones Brothers Trucking · HireRight, Inc., or another consumer reporting agency, will obtain the reports for the Company. Hire right, Inc., is located at 5151