Driver Application Non Authority

Applicant General Information (CDL & NON-CDL DRIVER)

It is DJK Transportation’s policy to provide equal opportunity with regard to all terms and conditions of hiring. The Company complies with federal and state laws prohibiting discrimination on the basis of race, color, religion, sex, national origin, disability, veteran status, age or any other protected characteristic. Any Driver Application submitted to DJK Transportation which contains omissions, incomplete information (if no specific answer, write “NONE”), or is missing other required forms or paperwork will not be reviewed. Incomplete applications and forms will be returned to sender for completion. THIS APPLICATION AND ALL INFORMATION SUBMITTED WITH THIS APPLICATION (INCLUDING COPIES OF DOCUMENTS) MUST BE CLEARLY LEGIBLE OR WILL BE RETURNED TO SENDER.

Applicant Name *
First
Last

Address *
Address Line 1
Address Line 2
City
State
Zip Code

Phone *

Email *
Email
Confirm Email

Previous Address
Address Line 1
Address Line 2
City
State
Zip Code

Do You have the Legal Right to Work in the U.S.? *
Yes
No

Have You Ever Been Convicted of a Felony (if yes, explain below)? *
Yes
No

License Information

License Number
ONLY NUMBERS ARE ALLOWED IN THIS SPACE! WE WILL CALL TO GET THE LETTER FROM YOUR DRIVERS LICENSE.

State *

License Type *
Class A - Any combination of motor vehicles with a gross combined weight rating (GCWR) of 26,001 pounds or more
Class B — Any single motor vehicle with a GVWR of 26,001 pounds or more or any such vehicle towing another not in excess of 10,000 pounds.
Class C — Any motor vehicle with a GVWR of more than 16,000 pounds but less than 26,001 pounds; or any such vehicle towing another with a GVWR of 10,000 pounds or less; or any such vehicle designed to carry 16 or more passengers, including the driver, or hazardous materials that require placarding.
Class D — Any motor vehicle with a GVWR of 16,000 pounds or less. Does not include A. B, C, L or M vehicles.
Class L — Any motor-driven cycle with less than 150cc displacement.
Class M — Any motorcycle or motor-driven cycle.

Expiration Date *

Have You Ever Been Denied a License, Permit, or Privilege to Operate a Motor Vehicle? *
Yes
No

Has Any License, Permit, or Privilege Ever Been Suspended or Revoked? *
Yes
No

Driving Experience

Type of Equipment

Date From: *

Date To: *

Number of Miles Driven *

Approximate No. of Total Miles:
Selected Value: 0

Any Accidents in Past Three (3) Years? *
Yes
No

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST THREE (3) YEARS (other than parking violations): *
Yes
No

Employment History

Category 3 (non-CDL) driver applicants must provide three (3) years of employment history (CDL driver applicants must provide ten (10) years of employment history). Add additional employment history pages, if needed. Any gaps in employment must be explained on a separate page and included with this application. All information obtained from previous employers/carriers will be kept confidential. Please list most recent employer/carrier first. Include complete address information (street number and name, city, state/territory, and zip/postal code).

Current / Last Employer Name *

Address *
Address Line 1
Address Line 2
City
State
Zip Code

Contact Name *
First
Last

Contact Phone Number *

Position *

From *//

To: *//

Reason For Leaving: *

Was Your Job Designated as a Safety-Sensitive Function in any DOT- Regulated Mode Subject to Alcohol & Controlled Substances Testing Under 49 CFR Part 40? *
Yes
No

Were You Subject to the Federal Motor Carrier Safety Regulations (FMCSRs)? *
Yes
No

Next Employer

Employer Name

Address
Address Line 1
Address Line 2
City
State
Zip Code

Contact Name
First
Last

Contact Phone Number

Position

From //

To://

Reason For Leaving: *

Was Your Job Designated as a Safety-Sensitive Function in any DOT- Regulated Mode Subject to Alcohol & Controlled Substances Testing Under 49 CFR Part 40? *
Yes
No

Were You Subject to the Federal Motor Carrier Safety Regulations (FMCSRs)? *
Yes
No

DRUG WAIVER AND CONSENT FORM

This must be completed and signed BEFORE the tests and mailed with the physical form directly to the DJK Transportation, Inc's. Safety Department.
I hereby voluntarily authorize a physician or clinic authorized by DJK TRANSPORTATION , INC. to take specimens of my urine to be tested for marijuana and/or controlled substances therein and to further determine the content thereof. I understand and agree that the physician or clinic will disclose the results of the test to DJK TRANSPORTATION, INC., AND SAFETY DEPARTMENT COMPANY, and release any employees and/or agents thereof from any and all claims or causes of action resulting from the disclosure of the test results to the parties designated herein. I hereby further agree to waive any physician-patient privilege that may otherwise exist with respect to the confidentiality of the test results. I understand that this consent and release is subject to revocation at any time, except to the extent that action has been taken in reliance hereon. In any event, this consent will remain in effect until revoked or upon termination of employment / work relationship with DJK TRANSPORTATION INC.

Date: *

Date of Birth: *

Name *
First
Last

Signature *

APPLICANT: PLEASE READ AND SIGN BELOW:

I authorize you to make sure investigations and inquiries to my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. 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 / work relationship, I understand that false or misleading information given in my applications or interview(s) may result in termination. I understand, also, that I am required to abide by all rules and regulations of the Company. “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 understand that I have the right to:
• Review information provided by current / previous employers (see note* below);
• Have errors in the information corrected by previous employers and for those employers to re-send the corrected information to the prospective employer/carrier; 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.”

Signature *

Date *

NOTE:

*NOTE: Drivers who have previous DOT-regulated employment history in the preceding three (3) years and wish to review previous employer-provided investigative information must submit a written request to the prospective employer / carrier. This may be done at any time, including when applying, or as late as thirty (30) days after being employed or being notified of denial of employment / work. Prospective employers / carriers must provide this information within five (5) business days of receiving the written request. If prospective employers / carriers have not yet received the requested information from the previous employer, then the five day deadline will begin when the requested safety performance history information is received. If you have not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer / carrier making them available, the prospective employer / carrier may consider you to have waived your request to review the record(s).

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

Signature *

Date *

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE

In connection with your application for employment with DJK TRANSPORTATION, INC. (“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 Prospective Employer uses any information it obtains from FMCSA in a decision not to hire you or to make any other adverse 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 action was based in part or in whole on the 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 part on information obtained from FMCSA; the name, address, and the toll free 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 Employee 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 DJK TRANSPORTATION ,INC. (“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 a crash or inspection information reported by a State, FMCSA cannot change or correct this data.

I understand my request will be forward 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.

Date *

Signature *

Name *
First
Last

PART I – DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES – 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulation 49 CFR Part 391.23 and 49 CFR part 40, each as applicable, I hereby authorize release of my DOT- regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to DJK TRANSPORTATION, INC. for the purpose of DJK Transportation, Inc. transmitting such records to the DJK Transportation, Inc. Listed above (Employer).

I understand that information/documents released pursuant to this Part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher alcohol concentration; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation.

If any company listed below furnishes DJK Transportation, Inc. with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to DJK Transportation, Inc., if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years.

List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature.

Previous DOT-Regulated Employer

Address
Address Line 1
City
State
Zip Code

Previous DOT-Regulated Employer

Address
Address Line 1
City
State
Zip Code

Phone

Previous DOT-Regulated Employer

Address
Address Line 1
City
State
Zip Code

Signature *
By my signature ABOVE, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form will be valid for any background checks that may be requested by or on behalf of the Customer.

Name *
First
Last

Social Security Number *

Date *

PART II – CONSUMER DISCLOSURE AND AUTHORIZATION FORM Disclosure Regarding Background Investigation

The Company may request, for lawful employment purposes, background information about you from a consumer reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable).

This background information may be obtained in the form of consumer reports and/or investigative consumer reports (commonly known as “background reports”).

An “investigative consumer report” is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews), the most common form of which is checking person or professional references. These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by the Company, throughout your employment or your contract period, as allowed by law.

Solutions, Inc. (Or any another consumer reporting agency, will prepare or assemble the background reports for the Company. DJK Transportation, Inc. Solutions, Inc. is located and can be contacted by mail at 14002 E. 21st Street, Suite 1200, Tulsa, OK 74134, and can be contacted by phone at (800) 381-064. Information about DJK Transportation, Inc.’s privacy practices is available at https://www.djktransportation.com/privacy-policy-2/.

The background report may contain information concerning 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; address history; credit reports and history; criminal records and history; public court records; driving records; accident history; worker’s compensation claims; bankruptcy filings; educational history verifications; (e.g., dates of attendance, degrees obtained); employment history verifications (e.g., dates of employment, salary information, reasons for termination, etc.); personal and professional references checks; professional licensing and certification checks; drug / alcohol testing results, and drug / alcohol history in violation of law and/or company policy; and other information bearing on your character, general reputation, personal characteristics, mode of living and credit standing.

This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses; educational institutions; former employers; and, for investigative consumer reports, personal interviews with sources such as neighbors, friends, former employers and associates; and other information sources. If the Company should obtain information bearing on your credit worthiness, credit standing or credit capacity for reasons other than as required by law, then the Company will use such credit information to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being evaluated.

You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.

A summary of your rights under the Fair Credit Reporting Act, as well as the FMCSA Notification of Driver Rights and certain state-specific notices, are provided.

Authorization of Background Investigation

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 preparation of background reports by a consumer reporting agency to release of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for other lawful purposes.

I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may, as allowed by law, obtain additional background reports pertaining to me, without asking for my authorization again, throughout my employment or contract period at DJK Transportation, Inc. and/or other consumer reporting agencies.

I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing contained herein shall be construed as an offer of employment or contract for services.

I hereby authorize all the following, without limitation, to disclose information about me to the consumer reporting agency and its agents: law enforcement and all other federal, state and local agencies, learning institutions (including public and private schools, colleges and universities), testing agencies, information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle record agencies, my past or present employers, the military, and all other individuals and sources with any information about or concerning me.

The information disclosed to the consumer reporting agency and its agents includes, but is not limited to, information concerning my employment and earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses.

By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form will be valid for any background reports that may be requested by or on behalf of the Company.

CA, MN or OK Residents ONLY
CA, MN or OK Residents ONLY
California, Minnesota or Oklahoma applicants only: Please check this box if you would like to receive (whenever you have such right under the applicable state law) a copy of your background report if one is obtained on you by the Company.

Name *
First
Middle
Last

Signature *

Date *

FMCSA REGULATIONS & INFORMATION REVIEW CONFIRMATION

It is each driver’s responsibility to be familiar with and comply with all FMCSA regulations. As such, DJK Transportation requires confirmation that you have reviewed the following regulations and information. Once you have confirmed that you have reviewed the information, please complete, sign and date this form and submit to the Safety Department (via fax at 773-498-4707 or email support@djktransportation.com).

To access the information, click on the links below.

You can also access the information by going to: http://www.fmcsa.dot.gov<

49 CFR Parts

40 Procedures for Transportation Workplace Drug and Alcohol Testing Programs (http://www.dot.gov/odapc/part40)

382 Controlled Substances and Alcohol Use and Testing (http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/FmcsrGuideDetails.aspx?menukey=382)

383 Commercial Driver's License Standards; Requirements and Penalties (http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/FmcsrGuideDetails.aspx?menukey=383)

391 Qualifications of Drivers and Longer Combination Vehicle (LCV) Driver Instructors (http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/FmcsrGuideDetails.aspx?menukey=391)

392 Driving of Commercial Motor Vehicles (http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/FmcsrGuideDetails.aspx?menukey=392)

393 Parts and Accessories Necessary for Safe Operation (http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/FmcsrGuideDetails.aspx?menukey=393)

395 Hours of Service of Drivers (http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/FmcsrGuideDetails.aspx?menukey=395)

396 Inspection, Repair, and Maintenance (http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/FmcsrGuideDetails.aspx?menukey=396)

In addition, we ask that you access the following websites to review information on: North American Standard Driver/Vehicle Inspection Levels (http://www.fmcsa.dot.gov/safety-security/safety-initiatives/mcsap/insplevels.htm)

CSA Information for Drivers (http://csa.fmcsa.dot.gov/yourrole/drivers.aspx)

By signing below, I confirm that I have accessed the links above and reviewed all the information contained therein.

Signature *

Date *

Applicant General Information (CDL & NON-CDL DRIVER)

License Information

Driving Experience

Employment History

Next Employer

DRUG WAIVER AND CONSENT FORM

APPLICANT: PLEASE READ AND SIGN BELOW:

NOTE:

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE

PART I – DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES – 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

PART II – CONSUMER DISCLOSURE AND AUTHORIZATION FORM Disclosure Regarding Background Investigation

FMCSA REGULATIONS & INFORMATION REVIEW CONFIRMATION

Useful Links

Subscribe for Newsletter

© 2019 DJK Transportation. A Transportation Company Licensed Under MC# 1040160

D-U-N-S NUMBER 118213765

Powered By: Forward Focused Solutions, Inc.

Driver Application Non Authority

Applicant General Information (CDL & NON-CDL DRIVER)

License Information

Driving Experience

Employment History

Next Employer

DRUG WAIVER AND CONSENT FORM

APPLICANT: PLEASE READ AND SIGN BELOW:

NOTE:

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE

PART I – DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES – 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

PART II – CONSUMER DISCLOSURE AND AUTHORIZATION FORM Disclosure Regarding Background Investigation

FMCSA REGULATIONS & INFORMATION REVIEW CONFIRMATION

Useful Links

Subscribe for Newsletter

© 2019 DJK Transportation. A Transportation Company Licensed Under MC# 1040160 D-U-N-S NUMBER 118213765Powered By: Forward Focused Solutions, Inc.

© 2019 DJK Transportation. A Transportation Company Licensed Under MC# 1040160

D-U-N-S NUMBER 118213765

Powered By: Forward Focused Solutions, Inc.