* = Required
Where did you hear about us? *
Applicant's Full Name* Address* City* State* Zip* Phone# (include 3 digit area code)* Cell Phone# (include 3 digit area code)* Message Phone# (include 3 digit area code) Date of Birth: Please include Date/Month/Year* Social Security #* E-Mail Address How Much Tractor Trailer Experience If Owner/Operator, Year and Make of Truck
Driver's License #* State* Type* Exp* Other state licenses held in the last 3 years list here (Ex: NY, WA) CDL-A?* choose Yes No Date of last physical exam. (mm/yy)* Number of tickets last 3 years* Number of accidents last 3 years*
Traffic convictions and forfeitures for the last 3 years (other than parking violations) Location Date Charge Location Date Charge Location Date Charge Location Date Charge
Last Accident Date Nature (Ex: Head-on, rear-end, upset, etc) Fatalities choose Yes No Injuries choose Yes No
Next Accident Date Nature (Ex: Head-on, rear-end, upset, etc) Fatalities choose Yes No Injuries choose Yes No
Next Accident Date Nature (Ex: Head-on, rear-end, upset, etc) Fatalities choose Yes No Injuries choose Yes No Have you ever had a DUI?* Choose No Yes If yes, when: Please include Date/Month/Year Have you ever had your license suspended or revoked? Choose No Yes If yes, when: Please include Date/Month/Year Have you ever been convicted of a felony or misdemeanor?* Choose No Yes If yes, when: Please include Date/Month/Year Have you tested positive for drugs or alcohol?* choose yes no Which? When? (mm/yy)
#1 Employer Employer's Name* Address* City* State* Phone# (include 3 digit area code)*
Dates of Employment: From:* To:*
Position Held * Reason for Leaving:*
#2 Employer Employer's Name Address City State Phone# (include 3 digit area code) Dates of Employment: From: To:
Position Held Reason for Leaving: #3 Employer Employer's Name Address City State Phone# (include 3 digit area code) Dates of Employment: From: To:
Position Held Reason for Leaving:
#4 Employer Employer's Name Address City State Phone# (include 3 digit area code) Dates of Employment: From: To:
Read information below and ensure all fields are completed before submitting form. If you do not fill out the form completely your application will NOT be processed!
“I certify that I personally completed this application and that all of the information is true and correct. Per section 391.23 I understand that I have the following rights: (1) to review information provided by the previous employers (DOT regulated history in the preceding 3 years). (2) to have errors in the information corrected by previous employers and for that previous employer to resend the corrected information to us, (3) to have a rebuttal statement attached to any alleged erroneous information, if you and a previous employer cannot agree on the accuracy of the information. Requests must be submitted in writing at any time including when applying or up to 30 days after being employed. (no fax or verbal requests). Further, you are hereby authorized to give K&B transportation/Artex, Inc. all information regarding my character, work habits, dates of employment, traffic offenses, credit experience and safety record. You are also authored to release the results of all drug and alcohol tests in accordance with sections 382.413, 382.405, 391.89, 391.23 of the Federal Motor Carrier Safety Regulations. You and K&B transportation/Artex Inc. are herby released from and liability which may result from giving such information in order to enable K&B transportation, Inc. to comply with the requirements of 382.413 and 391.23 of the FMCSR. I specifically authorize you to release information on any/all alcohol tests with a concentration of 0.04 or greater, positive controlled substance tests, and/or refusals to be tested writing (3) years preceding the date of this request. I authorize you to release any and all information pertaining to my evaluation by a substance abuse professional (SAP), the identity of that SPA, and my participation in any/all treatment or rehabilitation recommended by the SAP. I hereby authorize and direct my current and/or prior employers/lessors to release such information to You and K&B transportation/Artex Inc., in personal interviews, telephone interviews, letters, or any other method that ensures confidentiality, I hereby authorize You and K&B transportation/Artex Inc. to release such information to any of its personnel whose duties require them to assess this application and/or to make recommendations or decisions with respect to it. I have completed the application of my own free will and hold all clients of You and K&B transportation/Artex Inc., harmless of all liability for providing this application for my use.
You are hereby authorized to give to K&B Transportation/Artex, Inc. all information regarding my character, work habits, dates of employment, traffic offenses, credit, experience, & safety record. You are also authorized to release the results of all drug & alcohol tests in accordance with sections 382.413, 382.405, 391.89 & 391.23 of the Federal Motor Carrier Safety Regulations. You and K&B Transportation/Artex, Inc. are hereby released from any liability, which may result from giving such information, in order to enable K&B Transportation, Inc. to comply with the requirements of 382.413 & 391.23 of the FMCSR. I specifically authorize you to release information on any/all alcohol tests with a concentration of 0.04 or greater, positive controlled substance tests, and/or refusals to be tested within the three (3) years preceding the date of this request. I authorize you to release any and all information pertaining to my evaluation by a substance abuse professional (SAP), the identity of that SAP, and my participation in any/all treatment or rehabilitation recommended by the SAP, I hereby authorize and direct my current and/or prior employers/lessors to release such information to K&B Transportation/Artex, in personal interviews, telephone interviews, letters, or any other method that ensures confidentiality. I hereby authorize K&B Transportation/Artex to release such information to any of its personnel whose duties require them to assess this application and/or to make recommendations or decisions with respect to it. Under section 391.23(g)(1) you must reply with such information as soon as possible or NLT 30 days from the date of this request. Fax replies to: 402-494-1760
Your Full Name As It Appears On Your Driver's License:* Placing your name here signifies that you agree with the statement above. Please press submit button once.
