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DRIVER EMPLOYMENT APPLICATION

Solid Ground Transportation, LLC
Eckerty, IN 47116
812-472-8302
An Equal Opportunity Employer
Solid Ground Transportation, LLC (SGT) will not discriminate against any employee or applicant for employment because of race, color, religion, sex or national origin. SGT will take affirmative action to ensure applicants are employed, and employees are treated during employment, without regard to their race, color, religion, sex or national origin. Such action shall include, but not be limited to, the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay of other forms of compensation; and selection for training, including apprenticeship.
COMPLETE APPLICATION IN FULL OR IT WILL NOT BE CONSIDERED

APPLICANT INFORMATION

Position Applied For *

Driver
Owner/Operator

First Name *

Middle Name *

Last Name *

Phone *

Email *

Date Of Birth *

Date Available For Work *

Social Security Number *

Do you have legal right to work in the United States? *

Yes
No

PREVIOUS THREE YEARS RESIDENCY (Attach additional sheet if more space is required)

Current Physical Address *

Address Line 1

City

State

Zip Code

# Of Years At This Address *

Is Mailing Address Same As Physical Address? *

Yes
No

Mailing Address *

Address Line 1

City

State

Zip Code

2nd Physical Address? *

Yes
No

2nd Previous Physical Address

Address Line 1

City

State

Zip Code

# Of Years At This Address

3rd Physical Address?

Yes
No

Previous Physical Address

Address Line 1

City

State

Zip Code

# Of Years At This Address

4th Physical Address?

Yes
No

Previous Physical Address

Address Line 1

City

State

Zip Code

# Of Years At This Address

LICENSE INFORMATION

No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.
Current Driver's License Information:

State of Issue *

License # *

Type/Class *

Endorsements *

Expiration Date *

2nd Driver's License? *

Yes
No

2nd State of Issue

2nd License #

2nd Type/Class

2nd Endorsements

2nd Expiration Date

3rd Driver's License?

Yes
No

3rd State of Issue

3rd License #

3rd Type/Class

3rd Endorsements

3rd Expiration Date

DRIVING EXPERIENCE

Class Of Equipment *

Straight Truck
Tractor & Semi-Trailer
Tractor & 2 Trailers
Tractor & Tanker
Other

Type of Equipment (Van, Tank, Flat, Etc.) *

Date From *

Date To *

Approximate # of Miles *

ACCIDENT RECORD FOR PAST 3 YEARS (Attach additional sheet if more space is needed.)

Have You Been Involved In Any Accident(s) In The Past 3 Years? *

Yes
No

Accident #1. Date of Most Recent Accident

Accident #1. Nature of Accident (head-on, rear-end, upset, etc.)

Accident #1. Number of Fatalities

Accident #1. Number of Injuries

Accident #1. Chemical Spills?

Yes
No

2nd Accident To Report?

Yes
No

Accident #2. Date of Most Recent Accident

Accident #2. Nature of Accident (head-on, rear-end, upset, etc.)

Accident #2. Number of Fatalities

Accident #2. Number of Injuries

Accident #2. Chemical Spills?

Yes
No

3nd Accident To Report?

Yes
No

Accident #3. Date of Most Recent Accident (copy)

Accident #3. Nature of Accident (head-on, rear-end, upset, etc.)

Accident #3. Number of Fatalities

Accident #3. Number of Injuries

Accident #3. Chemical Spills?

Yes
No

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS - other than parking violations. (Attach additional sheet if more space is required.)

Have You Had Any Traffic Convictions and/or Forfeitures In The Past 3 Years? *

Yes
No

1. Date Convicted

1. Violation

1. State of Violation

1. Penalty (forfeited bond, collateral and/or points)

2nd Conviction to Report?

Yes
No

2. Date Convicted

2. Violation

2. State of Violation

2. Penalty (forfeited bond, collateral and/or points)

3nd Conviction To Report?

Yes
No

3. Date Convicted

3. Violation

3. State of Violation

3. Penalty (forfeited bond, collateral and/or points)

Have you ever been denied a license, permit, or priviledge to operate a motor vehicle? *

Yes
No

If yes, Explain:

Has any license, permit, or privilege ever been suspended or revoked? *

Yes
No

If yes, Explain:

EMPLOYMENT HISTORY

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.
Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.

Current (Most Recent) Employer Name *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Position Held *

Starting Date *

Ending Date *

Reason For Leaving *

Salary *

Explain any gaps in employment (Include month/year & reason)

While employed here, were you subject to the Federal Motor Safety Regulations? *

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CRF, part40? *

Yes
No

2nd Employer To Report? *

Yes
No

2nd Employer Name

2nd Employer Phone

2nd Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held - 2nd Employer

Starting Date - 2nd Employer

Ending Date - 2nd Employer

Reason For Leaving - 2nd Employer

Salary - 2nd Employer

Explain any gaps in employment (Include month/year & reason) - 2nd Employer

While employed here, were you subject to the Federal Motor Safety Regulations? - 2nd Employer

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CRF, part40? - 2nd Employer

Yes
No

3rd Employer To Report?

Yes
No

3rd Employer Name

3rd Employer Phone

3rd Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held - 3rd Employer

Starting Date - 3rd Employer

Ending Date - 3rd Employer

Reason For Leaving - 3rd Employer

Salary - 3rd Employer

Explain any gaps in employment (Include month/year & reason) - 3rd Employer

While employed here, were you subject to the Federal Motor Safety Regulations? - 3rd Employer

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CRF, part40? - 3rd Employer

Yes
No

EDUCATION

Did You Graduate High School? *

Yes
No

High School Name

High School Location

High School Course of Study

High School Years Completed

High School Details

Did You Complete Any College Courses? *

Yes
No

College Name

College Location

College Course of Study

College Years Completed

College Details

Do You Have Other Education To Report? *

Yes
No

Other Education Name

Other Education Location

Other Education Course of Study

Other Education Years Completed

Other Education Details

OTHER QUALIFICATIONS

Please list any other qualifications that you have and which you believe should be considered.

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, 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, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the company.

I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to:

- Review information provided by current/previous employers;

-Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; and

-Have a rebuttal statement attached to the alleged erroneous information, it the previous employer(s) and I cannot agree on the accuracy of the information.

This certifies that I have completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

Electronic Signature (Type Full Name) *

Signature (Sign With Mouse, Stylus or Finger) *

Clear Signature

Please upload a copy of your Driver's License here (.pdf, .png or .jpg files only) *

Click or drag a file to this area to upload.

Please upload a copy of your Long Form Physical here (.pdf, .png or .jpg files only) *

Click or drag a file to this area to upload.

MVR RELEASE CONSENT FORM

In conjunction with my employment, or volunteer work, at/with Solid Ground Transportation, LLC (company), I ______________________________ (applicant) consent to the release of my Motor Vehicle (MVR) to the company. I understand the company will use these records to evaluate my suitability to fulfill driving duties that may be related to the position for which I am applying. I also consent to the review, evaluation, and other use of any MVR I may have provided to the company. This consent is given in satisfaction of Public Law 18 USC 2721 et. Seq.. "Federal Drivers Privacy Protection Act", and is intended to constitute "written consent" as required by this act.

Signature (sign with finger, Stylus or mouse)

Clear Signature

Driver's License Number *

State *

Date-Of-Birth *

Social Security # *

Date *

Pre-Employment | Random | Post Accident | Return To Duty | Follow Up | Reasonable Suspicion

SAFETY PERFORMANCE HISTORY RECORDS REQUEST PART 1: | TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name): First, M.I., Last *

Social Security Number *

Date Of Birth *

Hereby authorize Previous Employer (Name) *

Address *

Address Line 1

City

State

Zip Code

Email *

Phone *

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:

To:
Solid Ground Transportation, LLC
Attn: Brenda Conley
6270 W Governors Trace
Eckerty, IN 47116
812-472-8302
In compliance with SS40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.
Solid Ground's Email Address: solidgroundtrans@gmail.com

Applicant's Signature (sign with finger, Stylus or mouse)

Clear Signature

Date

This information is being requested in compliance with SS40.25(g) and 391.23(h).

PART 2: | TO BE COMPLETED BY PREVIOUS EMPLOYER
Accident History

The applicant named above was employed by us

Yes
No

Employed as:

from (m/y)

Date

Time

to (m/y)

Date

Time

1. Did he/she drive motor vehicle for you?

Yes
No

If yes, what type?

Straight Truck
Tractor-Semitrailer
Bus
Cargo Tank
Doubles/Triples
Other

Specify

2. Reason for leaving your employ:

Discharged
Resignation
Lay Off
Military Duty

If there was no safety performance history to report, check here, sign and return.

None

ACCIDENTS: Complete the following for any accidents included on your accident register (SS390.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or

Check here if there is no accident register date for this driver.

None

#1 Accident Date

#1 Accident Location

#1 Accident: # of injuries

#1 Accident: # of fatalities

#1 Accident: Hazmat Spill

2nd Accident to Report?

Yes
No

#2 Accident Date

#2 Accident Location

#2 Accident: # of injuries

#2 Accident: # of fatalities

#2 Accident: Hazmat Spill

3rd Accident to Report?

Yes
No

#3 Accident Date

#3 Accident Location

#3 Accident: # of injuries

#3 Accident: # of fatalities

#3 Accident: Hazmat Spill

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 (sign with finger, Stylus or mouse)

Clear Signature

Title:

Date:

Solid Ground Transportation, LLC

Eckerty, Indiana 47116

1.812.472.8302

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Solid Ground Transportation, LLC

Eckerty, Indiana 47116

1.812.472.8302

Indiana Website Design
WebsitesThatWork.biz

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