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GW Navigation Docs Driver Application PDF
GW Navigation Docs Driver Application PDF
Signature
Date
411 Brisbane Houston, Texas 77061 Tel. (713) 747-4909 Fax. (713) 440-5784 www.gwii.com
Address
Street City
Phone No.
State Zip Code
Cell phone No:
Address for the past 3 years
How Long
Street/City/State/Zip Code
How Long
Street/City/State/Zip Code
Do you have legal right to work in the United States?
Date of Birth
Can you provide proof of age?
(Required for Truck Drivers)
Have you worked for this company before?
Where?
Dates: from
Position
to
Rate of Pay
Is there any reason you might be unable to perform the functions of the job for which you have applied?
If yes, please explain
(LIST ALL DRIVING JOBS FOR THE PAST THREE (3) YEARS)
TELEPHONE NO.
CONTACT PERSON
ADDRESS POSITION
FROM /
TO /
REASON FOR LEAVING
Were you subject to the FMCSRs while employed?
Yes No Was your job designated as a safety-sensitive
function in any DOT-regulated mode subject to the Drug and Alcohol testing requirement of 49CFR? Yes No
EMPLOYER
TELEPHONE NO.
CONTACT PERSON
ADDRESS POSITION
FROM /
TO /
REASON FOR LEAVING
Were you subject to the FMCSRs while employed?
Yes No Was your job designated as a safety-sensitive
function in any DOT-regulated mode subject to the Drug and Alcohol testing requirement of 49CFR? Yes No
EMPLOYER
TELEPHONE NO.
CONTACT PERSON
ADDRESS POSITION
FROM /
TO /
REASON FOR LEAVING
Were you subject to the FMCSRs while employed?
Yes No Was your job designated as a safety-sensitive
function in any DOT-regulated mode subject to the Drug and Alcohol testing requirement of 49CFR? Yes No
EMPLOYER
TELEPHONE NO.
CONTACT PERSON
ADDRESS POSITION
FROM /
TO /
REASON FOR LEAVING
Were you subject to the FMCSRs while employed?
Yes No Was your job designated as a safety-sensitive
function in any DOT-regulated mode subject to the Drug and Alcohol testing requirement of 49CFR? Yes No
EMPLOYER
TELEPHONE NO.
CONTACT PERSON
ADDRESS POSITION
FROM /
TO /
REASON FOR LEAVING
Were you subject to the FMCSRs while employed?
Yes No Was your job designated as a safety-sensitive
function in any DOT-regulated mode subject to the Drug and Alcohol testing requirement of 49CFR? Yes No
EMPLOYER
TELEPHONE NO.
CONTACT PERSON
ADDRESS POSITION
FROM /
TO /
REASON FOR LEAVING
Were you subject to the FMCSRs while employed?
Yes No Was your job designated as a safety-sensitive
function in any DOT-regulated mode subject to the Drug and Alcohol testing requirement of 49CFR? Yes No
(LIST ALL DRIVING JOBS FOR THE PAST THREE (3) YEARS)
TELEPHONE NO.
CONTACT PERSON
ADDRESS POSITION
FROM /
TO /
REASON FOR LEAVING
Were you subject to the FMCSRs while employed?
Yes No Was your job designated as a safety-sensitive
function in any DOT-regulated mode subject to the Drug and Alcohol testing requirement of 49CFR? Yes No
EMPLOYER
TELEPHONE NO.
CONTACT PERSON
ADDRESS POSITION
FROM /
TO /
REASON FOR LEAVING
Were you subject to the FMCSRs while employed?
Yes No Was your job designated as a safety-sensitive
function in any DOT-regulated mode subject to the Drug and Alcohol testing requirement of 49CFR? Yes No
EMPLOYER
TELEPHONE NO.
CONTACT PERSON
ADDRESS POSITION
FROM /
TO /
REASON FOR LEAVING
Were you subject to the FMCSRs while employed?
Yes No Was your job designated as a safety-sensitive
function in any DOT-regulated mode subject to the Drug and Alcohol testing requirement of 49CFR? Yes No
EMPLOYER
TELEPHONE NO.
CONTACT PERSON
ADDRESS POSITION
FROM /
TO /
REASON FOR LEAVING
Were you subject to the FMCSRs while employed?
Yes No Was your job designated as a safety-sensitive
function in any DOT-regulated mode subject to the Drug and Alcohol testing requirement of 49CFR? Yes No
EMPLOYER
TELEPHONE NO.
CONTACT PERSON
ADDRESS POSITION
FROM /
TO /
REASON FOR LEAVING
Were you subject to the FMCSRs while employed?
Yes No Was your job designated as a safety-sensitive
function in any DOT-regulated mode subject to the Drug and Alcohol testing requirement of 49CFR? Yes No
EMPLOYER
TELEPHONE NO.
CONTACT PERSON
ADDRESS POSITION
FROM /
TO /
REASON FOR LEAVING
Were you subject to the FMCSRs while employed?
Yes No Was your job designated as a safety-sensitive
function in any DOT-regulated mode subject to the Drug and Alcohol testing requirement of 49CFR? Yes No
DATES
NATURE OF ACCIDENT
(HEAD-ON, REAR-END, UPSET, ETC.)
FATALITIES
INJURIES
LAST ACCOUNT
NEXT PREVIOUS
NEXT PREVIOUS
LOCATION
DATE
DRIVER LICENSES #
A.
B.
C.
D.
CHARGE
PENALTY
EDUCATION
1 2 3 4 5 6 7 8
HIGH SCHOOL: 1 2 3 4
(NAME)
COLLEGE:
1 2 3 4
(CITY)
EXPIRATION DATE
HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE ?
HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED?
HAVE YOU EVER BEEN ARRESTED OR CONVICTED OF A FELONY?
HAVE YOU EVER BEEN ARRESTED OR CONVICTED OF A MISDEMEANOR?
YES
YES
YES
YES
NO
NO
NO
NO
IF THE ANSWER TO ANY OF THE ABOVE IS YES, ATTACH STATEMENT GIVING DETAILS.
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT
(VAN, TANK, ETC.)
FROM
DATES
TO
STRAIGHT TRUCK
TRACTOR AND SEMI-TRAILER
TRACTOR - TWO TRAILERS
MOTOR COACH - SCHOOL BUS
OTHER
LIST STATES OPERATED IN FOR LAST FIVE YEARS
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER
Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more
passengers or and size vehicle used to transport hazardous materials in a quantity requiring placarding.
TRUCK INFORMATION
Make
Year
Empty Weight
Date of last DOT inspection
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER
THAN THOSE ALREADY SHOWN)
Date
c.) Prior to collection of a urine sample under 391.107 of this subpart, a driver-applicant
shall be notified that the sample will be tested for the presence of controlled substances.
APPLICANTS SIGNATURE
I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign
this consent form, 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
SECTION 1:
I, (Print Name)
First, M. I., Last
Social Security Number
hereby authorize:
Date of Birth
Previous Employer:
Email:
Street:
Telephone:
City, State, Zip:
Fax No.:
to release and forward the information requested by Section 3 of this document concerning my Alcohol and Controlled Substances Testing
records within the previous 3 years from
.
(date of employment application)
To:
Prospective Employer:
Attention:
Street:
Telephone:
Applicants Signature
Date
SECTION 2:
to (m/y)
1. Did he/she drive motor vehicle for you? Yes o No o If yes, what type? Straight Truck o Tractor-Semitrailer o Bus
Cargo Tank o Doubles/Triples o Other (Specify)
2. Reason for leaving your employ: Discharged o Resignation o Lay Off o Military Duty
If there is no safety performance history to report, check here o, sign below and return.
ACCIDENTS: Complete the following for any accidents included on your accident register (390.15(b)) that involved the
applicant in the 3 years prior to the application date shown above, or check here o if there is no accident register data for this
driver.
Date
Location
No. of injuries No. of Fatalities Hazmat Spill
1.
2.
3.
Please provide information concerning any other accidents involving the applicant that were reported to government agencies
or insurers or retained under internal company policies:
Any other remarks:
Signature:
Title:
Date: