Driver Application

Employment Application

Step 1 of 9 - Personal Information

Personal Information
Name*
First Last
Current Address*
Street Address City State ZIP Code
How long have you been at this Address?*
Email*
Phone*
Date of Birth*
MM slash DD slash YYYY
Social Security Number*

Please enter your 10 digit SS number
Drivers License Info
State of License*
State
License #*
License Expiration Date*
MM slash DD slash YYYY
DOT Med Card Expiration Date
MM slash DD slash YYYY

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Address History
List your previous addresses of residency for the past 3‐years if different fromn current address:
Address #1
Street Address City State ZIP Code
How long did you live at Address #1?
Address #2
Street Address Address Line 2 City State ZIP Code
How long did you live at Address #2?
Address #3
Street Address Address Line 2 City State ZIP Code
How long did you live at Address #3?

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Driving History
Vehicle Type*
Number of Driving Years Experience*
Violations
Please list all your traffic violations for the last 3 Years.
Check if not applicable
- I have had no violations in the last 3 years
Violation #1

Please Enter the date, location, the charge and type of vehicle you were driving at the time.
Violation #2

Please enter the date, location, the charge and type of vehicle you were driving at the time.
Violation #3

Please enter the date, location, the charge and type of vehicle you were driving at the time.
Violation #4

Please enter the date, location, the charge and type of vehicle you were driving at the time.
Violation #5

Please enter the date, location, the charge and type of vehicle you were driving at the time.
Accidents
Please list all your traffic accidents for the last 3 years.
Check if not applicable
- I have had no accidents in the last 3 years
Accident #1

Please enter the date, location, a description of what happened and type of vehicle you were driving at the time.
Accident #2

Please enter the date, location, a description of what happened and type of vehicle you were driving at the time.
Accident #3

Please enter the date, location, a description of what happened and type of vehicle you were driving at the time.
Accident #4

Please enter the date, location, a description of what happened and type of vehicle you were driving at the time.
Accident #5

Please enter the date, location, a description of what happened and type of vehicle you were driving at the time.
Has your license ever been suspended or revoked?*
- Yes
- No
Date Revoked
MM slash DD slash YYYY
Reason for being revoked
List all the states you've operated in over the past 3 years*

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TO BE READ AND SIGNED BY APPLICANT
REQUIRED*
- I agree to these terms
This certifies that I completed this application, and that all entries, and information documented by me are true and complete to the best of my knowledge. By my signature heretofore, I acknowledge having been given this carrier which has presented me with this application, a statement of my right to due process as outlined by all parts of 49 CFR Part 391.23 of the Federal Motor Carrier Safety Regulations effective October 29, 2004. Having made this acknowledgement, I therefore authorize you to make such previous employment and background investigation and inquire of my personal, employment, financial or medical history, and other related matters as may be necessary to arrive at a possible employment decision. (Generally, inquires regarding medical history will be made only if and after a conditional offer of employment has been extended.) 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 rules and regulations of the company.
E-Signature*
First Last
Please type name to sign application and date below
Date*
MM slash DD slash YYYY

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Document Uploads
Upload files of the requested documents below.
Driver's License
Max. file size: 64 MB.
Please upload an image of your current, valid driver's license.
3-Year MVR
Max. file size: 64 MB.
Please upload a copy of your most recent MVR dating back 3 years.
Medical Card
Max. file size: 64 MB.
Please upload a copy of your most recent Medical Card
Social Security Card
Max. file size: 64 MB.
Please upload a copy of your valid Social Security Card

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CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.n
The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transport hazardous materials that require placarding.n
DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirement that you are a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:n
1. POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator’s license.nIf you have more than one license, keep the license from your state of residence and return the additional licenses to the state that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If multiple license has been lost, stolen, or destroyed, close your record by notifying the state issuance that you no longer want to be licensed by that state.n
2. NOTIFICATION OF LICENSE SUSPENNSION, REVOCATION OR CANCELLATION:nSection 391.15(b)(2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30‐days to:n
1). Your employing motor carrier, andn
2). The state that issued your license (if the violation occurs in the state other than the one whichnissued your license).n
The notification to both the employer an state must be in writing.
DRIVER CERTIFICATION*
- I certify that I have read and understood the CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS requirements.
Date*
MM slash DD slash YYYY
E-Signature*
First Last
AUTHORIZATION AND CONSENT FOR DRUG AND ALCOHOL TESTING
I UNDERSTAND THIS COMPANY ADMINISTERS A Drug‐Free Workplace Program. This program is incorporated in an overall substance abuse policy that is designed to create a drug/alcohol free work environment and transportation system. The program has been developed in compliance with existing federal regulation and company policies.n
This policy is not a contract or a guarantee, but a serious attempt to protect the safety of employees and the public.n
I understand all test results are treated confidentially per federal regulation and company policies.n
I agree to indemnify and hold harmless the company and it’s employees and agents from any loss, damage,nexpenses or other injury arising as a result of any information or disclosure authorized by this form.
Testing may be conducted but will not be limited to the following reasons:n
- Pre Employment nn
- Return to Duty nn
- Post Accident nn
- Post Injury nn
- Reasonable Suspicion
DRIVER CERTIFICATION*
- I certify that I have read and understood the AUTHORIZATION AND CONSENT FOR DRUG AND ALCOHOL TESTING requirements.
E-Signature*
First Last
Date*
MM slash DD slash YYYY
ACCIDENT REPORTING GUIDELINES
All accidents, no matter how minor must be reported to the Safety Department as soon as possible, after the incident. Failure to do so could result in disciplinary actions up to and including discharge. You could also be subject to criminal actions brought by Federal, State, or Local regulatory agencies. The following actions should be taken in the event of an accident.n
1. STOP IMMEDIATELY! You may be subject to drug or alcohol testing. DO NOT MOVE THE VEHICLE UNTIL YOU SPEAK WITH THE DIRECTOR OF SAFETY AT THE TERMINAL OFFICE. (404) 924‐7090n
2. Take all the necessary precautions to prevent further accidents at the scene. PUT YOUR TRANGLES OUT.n
3. Take pictures with company provided camera.n
4. Render all reasonable assistance to injured persons. *** Movement of injured persons by the drivernshould not be under taken if likely to cause further injury. ***n
5. Contact Police or Fire Department local or state. If you receive a citation, DO NOT move the vehiclenuntil you speak with the Safety Department.n
6. Contact the company: (404) 924‐7090.n
7. Complete accident information forms supplied by company (Accident kits are a part of your Pre‐nTrip Inspection). Check with your dispatcher if you do not have one!n
8. Get the following information:n
a. Vehicle description, license number and issuing staten
b. Insurance carrier and policy number of all vehicles involvedn
c. Names, addresses and phone numbers of all occupants of the vehicles
d. Statement from all occupantsn
e. Names, address and telephone numbers of any witnessesn
Be polite, but offer no opinions as to the cause of the accident. Cooperate fully with the law enforcement authorities, or scene commander. Do not discuss with an insurance adjuster or insurance agent representative any aspect of the accident unless authorized by the Safety Department. Upon returning to the terminal, call the Safety Department to complete necessary accident report forms and to completely review the details
DRIVER CERTIFICATION*
- I certify that I have read and understood the ACCIDENT REPORTING GUIDELINES requirements.
Date*
MM slash DD slash YYYY
E-Signature*
First Last
UNAUTHORIZED PASSENGERS
Unless specifically authorized in writing, to do so by the motor carrier under whose authorization the motor vehicle is being operated, no driver shall transport any person or permit any person be transported on any motor vehicle other than by bus.n
When such authorization is issued, it shall state the name of the person to be transported, the points where his/her transportation is to begin and end, and the date upon which authority expires.n
No written authorization, however, shall be necessary for the transportation of:n
Employees or other persona assigned to a vehicle by the motor carrier.n
Any person transported when aid is being rendered in cares of accident or other emergency.n
An attendant delegated to care for livestock.n
Your failure to abide by the requirement may subject you to disciplinary action up to and including discharge, disqualification, under the CFR (Code of Regulations) or possibility prosecution by the Department of Transportation.
DRIVER CERTIFICATION*
- I certify that I have read and understood the UNAUTHORIZED PASSENGERS requirements.
Date*
MM slash DD slash YYYY
INTOXICATING BEVERAGE
1. No person shall ...........n
- Consume an intoxicating beverage, regardless of its alcoholic content, or be under the influence of an intoxicating beverage within 12 hours before going on duty or operating, or having physical control of a motor vehicle; orn
- Consume an intoxicating beverage, regardless of alcoholic content, or be under the influence of an intoxicating beverage, while on duty, or operating, or in physical control of a motor vehicle; orn
- Be on duty or operate a motor vehicle while he/she possesses an intoxicating beverage, regardless of the alcoholic content. However, this subparagraph does not apply to possession of an intoxicating beverage which is manifested and transported as part of a shipment.n
2. No motor carrier shall inquire or permit a driver to ..............n
- Violate any provision of paragraph (1) OF THIS SECTION, ORn
- Be on duty or operate a motor vehicle if, by he/she appears to have consumed an intoxicatingnbeverage within the preceding 12 hours.n
Your failure to abide by the requirement may subject you to disciplinary action up to and including discharge, disqualification under the CFR (Code of Federal Regulations) or possibly prosecution by the Department of Transportation.
DRIVER CERTIFICATION*
- I certify that I have read and understood the INTOXICATING BEVERAGE requirements.
Date*
MM slash DD slash YYYY
E-Signature*
First Last
NARCOTICS‐AMPHETAMINES
No person shall operate, or be in physical control of a motor vehicle if he/she possess or is under the influence of, or in using any of the following substances:n
- A narcotic drug or any derivative thereof.n
- An amphetamine or any formulation of thereof (including, but not limited to, “pep‐pills and “bennies”).n
- Any other substance or a degree which renders him/her incapable of safely operating a motor vehicle.n
Your failure to abide by the requirement may be subject to disciplinary action up to and including discharge, disqualification under the CFR (Code of Federal Regulations) or possibly prosecution by the Department of Transportation.
DRIVER CERTIFICATION*
- I certify that I have read and understood the NARCOTICS‐AMPHETAMINES requirements.
Date*
MM slash DD slash YYYY
E-Signature*
First Last
SEAT BELTS
A motor vehicle has a seat belt assembly installed at the driver’s seat and shall not be driven unless the driver has properly restrained him/herself with seat belt.n
After June 30, 1972, every bus, truck, and tractor manufactured on or after January 1, 1965 must be equipped with seat belts assembly installed at the driver’s seat and at the right outboard seat if the vehicle has one.n
Your failure to abide by the requirement may subject to your disciplinary action up to and including discharge, disqualification under the CR (Code of Federal Regulations) or possibly prosecution by the Department of Transportation
DRIVER CERTIFICATION*
- I certify that I have read and understood the SEAT BELTS requirements.
Date*
MM slash DD slash YYYY
E-Signature*
First Last
SPEEDING
Section 392.2 of the Federal Motor Carrier Safety Regulations requires that every vehicle to be operated in accordance with the laws and ordinances and regulations of the jurisdiction in which the vehicle is being operated.n
Section 392.6 of the Federal Motor Carrier Safety Regulations restricts the operation of any motor vehicle between points in such period of time as would necessitate the vehicle be operated at speeds greater than those prescribed by the jurisdiction in or through which the vehicle is being operated.n
The meanings of these sections are simply ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ NO SPEEDING!!!!!!!!!!!!!!!!!!!!!!!!!!!!n
If your logs indicate that you traveled 565 miles in 10 hours, the entire distance is covered by a 55 mph zone, it can be concluded that you were SPEEDING and you may be held accountable under the Federal requirements mentioned above.n
Your failure to abide by the requirement may subject you to disciplinary action up to and including discharge, disqualification under the CFR (Code of Regulations) or possibly prosecution by the Department of Transportation.
DRIVER CERTIFICATION*
- I certify that I have read and understood the SPEEDING requirements.
Date*
MM slash DD slash YYYY
E-Signature
First Last

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ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK
I acknowledge receipt of the DISCLOSURE REGARDING CONSUMER AND/OR INVESTIGATIVE REPORT and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company, INPAX Shipping Solutions, at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, local, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Accurate Background, Inc., 7515 Irvine Center Drive, Irvine, CA 92618, (800) 216-8024, another outside organization acting on behalf of the Company, and/or the Company itself.n
I understand that by signing my name below, that I am signing the Authorization form directing the background check as described above, and I certify that:n
I understand that my signature now and throughout this process will be binding. Additionally, notices, documents, and communications may be provided electronically and will meet the requirements set forth under Federal and/or State law, as permitted by law.
Have you ever been convicted of a Felony or a misdemeanor charge?*
- Yes
- No
If yes, please briefly explain the type of offense, date and location of occurrence and the disposition.
Name*
Other Names Known By
Social Security Number*
Date of Birth*
MM slash DD slash YYYY
Driver's License*
State*
State
Address*
Street Address City State ZIP Code
Date*
MM slash DD slash YYYY
E-Signature*
First Last
Prospective Employer: INPAX Shipping Solutions*
- I agree that a facsimile (“fax”), electronic or printout of this authorization may be accepted with the same authority as the original.
Untitled
E-Signature*
First Last

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Employment Application

Step 1 of 9 - Personal Information

Personal Information

Drivers License Info

Address History

Driving History

Violations

Accidents

Work History

Background Information

TO BE READ AND SIGNED BY APPLICANT

Document Uploads

CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

AUTHORIZATION AND CONSENT FOR DRUG AND ALCOHOL TESTING

ACCIDENT REPORTING GUIDELINES

UNAUTHORIZED PASSENGERS

INTOXICATING BEVERAGE

NARCOTICS‐AMPHETAMINES

SEAT BELTS

SPEEDING

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK