Driver Application  
Personal Information
Contact Information
Full Name:
Address 1:
Address 2:
City:
State: Zip:
Day Phone: Cell Phone:
Night Phone:
Email: Best time to call:
SSN:
Date of Birth #:
How did you hear about us? (Please be specific):
CDL Information
Do you have a CDL?  Yes  No CDL Number:
Issue State: Expiration Date:
Previous Number: Previous Issue State:
Check all that apply to your current CDL:
Class A Hazmat
Double Passenger Air Brake
Driver Information
I am a ... (Check all that apply. One field must be chosen):
Company Driver Owner Operator Student
Check any teaming preference that applies:
Single Team Husband and Wife
 I am currently part of a team   **If so, enter your partner's name and contact information below.
Date Available:
Check all that apply:
I need training I am a Driving School Graduate
School name: When:
Experience and Preference
Total OTR years:
Trailer Type Experience and Preference
TRAILER TYPE EXPERIENCE YEARS PREFERS
Flatbed
Van
Employment History
I am currently employed. Number of jobs in last 3 years
Current Employer
Employer name :
Address Phone
City State Zip
Start date
End date
Position held
Supervisor You may contact this employer
Reason left
Vehicle driven Length of truck  
Previous Employer#1
Employer name :
Address Phone
City State Zip
Start date
End date
Position held
Supervisor You may contact this employer
Reason left
Vehicle driven Length of truck  
Previous Employer#2
Employer name :
Address Phone
City State Zip
Start date
End date
Position held
You may contact this employer
Reason left
Vehicle driven
Previous Employer#3
Employer name :
Address Phone
City State Zip
Start date
End date
Position held
Supervisor You may contact this employer
Reason left
Vehicle driven Length of truck  
Additional Employment Information
Owner Operator
(Not an Owner Operator? Please skip this section)
Tractor
Do you own your tractor?   Yes  No Manufacturer
Year Model
Fifth wheel height
Wheel base
Driving History
Accidents
Number of accidents involved
Number of preventable accidents
Number of roll-over accidents
Tickets
Number of tickets received
Number of preventable tickets
Number of reckless tickets
Addition Driving History Information
Criminal Record
If so, when...
Have you ever been convicted of a felony? Yes  No
Have you ever been convicted, or are any charges pending, for driving while under the influence of alcohol, a narcotic drug, amphetamines or derivatives thereof? Yes  No
Have you ever been convicted of a crime or have any charges pending? Yes  No
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
Have you ever tested positive or refused a test for drugs or alcohol? Yes  No
Have you ever abandoned your equipment? Yes  No
Comments
I certify that I personally completed this application and that all of the information is true and correct. I authorize the B-T, Inc. or their agents to make investigations, inquiries and to obtain any and all information and /or reports regarding my personal, employment, financial or medical history in accordance with state and federal laws in order to arrive 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.

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 any corrected information to the B-T, Inc.. I have the right to have a rebuttal statement attached to alleged erroneous information, if the previous employer(s) and I cannot agree on accuracy. 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 and drug & alcohol testing records as required by 49 CFR 391.23(d) and (e).

I understand that false or misleading information in this application will be considered an act of dishonesty and disqualify me from further consideration and that I am subject to immediate termination if this becomes known after employment has begun. Applicants not offered employment will not be provided any detail, as company policy does not allow disclosure of this information. I understand the policy not to provide any reasons or details if employment/lease is not offered, and I agree to be bound by the policy. When an employment decision is based in whole or in part upon a consumer report, I will be notified in compliance with the Fair Credit Reporting Act. By my signature below, I certify that I am a bona fide applicant for employment/lease and this application is being submitted solely for the purpose of seeking employment/lease and for no other purpose.

I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be "at will" and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the Company. No promises regarding employment have been made to me, and I understand that no such promise, or guarantee is binding upon the Company unless made in writing.

If I am offered employment I agree to submit to a medical examination and drug test before starting work. I consent to such examinations and tests, and I request that the examining doctor disclose to the Company the results of the examination, which results shall remain confidential and segregated from my personnel file. I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drug test, and if I am hired a condition of my employment will be that I abide by the Company's Drug and Alcohol Policy. I understand that I am required to abide by all rules and regulations of the Company.

 In connection with your application for employment with B-T, Inc. ("Prospective Employer"), it may obtain one or more reports regarding your credit, driving, and/or criminal background history from a consumer reporting agency and/or other sources. If the Prospective Employer uses any information it obtains from a background report 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 a background report, the Prospective Employer will notify you that the action has been taken and that the background report was the reason for the action. The Prospective Employer cannot obtain background reports from consumer reporting agencies or other sources regarding you unless you consent in writing.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize B-T, Inc. ("Prospective Employer") to contact any organization or individual that I have listed on my employment application or resume or mentioned in job interviews and obtain from them any relevant information about my job qualifications, including my experience, skills, and abilities. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years, as well as any reference-related information about me held or known by my former employers, supervisors, and co-workers. In addition, I consent to the release of any information about my education, experience, abilities, or work-related characteristics or traits held or known by other organizations or individuals, including schools and educational institutions, professional or business associates, and friends and acquaintances that Prospective Employer might contact in the course of conducting a reference check or background investigation of my suitability for employment.

I understand and acknowledge that this release of information can involve my qualifications, performance, credentials, or other characteristics or factors affecting my suitability for employment with Prospective Employer. Specifically, I am authorizing the release of any information about my performance, experience, capability, attitude, specific events, or other work-related characteristics that currently are in the possession of the requested organizations or their managers or representatives.

In exchange for Prospective Employer's consideration of my employment application, I agree not to file or pursue any complaints, claims, or legal actions of any kind against any organization or individual that provides work-related information about me to Prospective Employer or its agents in accordance with the terms and intent of this release.

I also agree not to file or pursue any complaints, claims, or legal actions against Prospective Employer or any of its employees, representatives, or agents arising out of their efforts to obtain work-related information about me.

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 and/or any entity it retains to obtain such background reports may obtain reports of my credit, driving, and/or criminal background history in addition to information regarding my background, references, education, specific events, and past employment.

I hereby authorize Prospective Employer and its employees, agents, and affiliates to obtain the information authorized above.
I have read the above release and I give permission to obtain consumer reports about me from HireRight DAC Trucking.
Yes  No

Would you like to receive emails from this carrier regarding future positions?
Yes  No
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