The application can be completed over multiple sessions. You will receive an email confirmation after completing each of the sections below.

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Section 3: Employment History
This timeline must be accurate and complete for the previous 10 years, including all periods of unemployment or and/or time out of the country exceeding one month. Begin with your current or most recent held job. 
Applicant's Full Name
» Previous Employer
Company Name:full name
Supervisor's Name:full name
Address:
Phone:full name
Fax:full name
Position Held:
From (MM/DD/YYYY):
To (MM/DD/YYYY):full name
Salary:
Equipment Operated: 
Other Equipment Operated
0 /
Number of Milesfull name
Reason For Leaving
Were you subject to Federal Motor Carrier Safety Regulations while employed by this employer?
Was the job a “SAFETY SENSITIVE FUNCTION” in any DOT related mode subject to Alcohol and Controlled Substances Testing requirements as required by 49 CFR part 40?
» Employer
Employer:
Supervisor's Name:
Address:full name
Phone:full name
Fax:
Position Held:full name
From (MM/DD/YYYY):
To (MM/DD/YYYY)
Salary:full name
Equipment Operated: 
Other Equipment Operated
0 /
Number of Milesfull name
Reason For Leavingfull name
Were you subject to Federal Motor Carrier Safety Regulations while employed by this employer?
Was the job a “SAFETY SENSITIVE FUNCTION” in any DOT related mode subject to Alcohol and Controlled Substances Testing requirements as required by 49 CFR part 40?
» Employer
Employer:full name
Supervisor's Name:
Address:full name
Phone:full name
Fax:full name
Position Held:full name
From (MM/DD/YYYY):full name
To (MM/DD/YYYY)full name
Salary:full name
Equipment Operated: 
Other Equipment Operated
0 /
Number of Milesfull name
Reason For Leavingfull name
Were you subject to Federal Motor Carrier Safety Regulations while employed by this employer?
Was the job a “SAFETY SENSITIVE FUNCTION” in any DOT related mode subject to Alcohol and Controlled Substances Testing requirements as required by 49 CFR part 40?
» Employer
Employer:full name
Supervisor's Name:
Address:full name
Phone:full name
Fax:full name
Position Held:
From (MM/DD/YYYY):full name
To (MM/DD/YYYY)full name
Salary:full name
Equipment Operated: 
Other Equipment Operated
0 /
Number of Milesfull name
Reason For Leavingfull name
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer?
Was the job a “SAFETY SENSITIVE FUNCTION” in any DOT related mode subject to Alcohol and Controlled Substances Testing requirements as required by 49 CFR part 40?
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Section 4: Applicant Rights and Consent

Information in this application will be used and prior employers will be contacted for purposes of Investigation as required by the FMCSR. It is agreed and understood that the employer or its agents may investigate the applicant's background to obtain any and all information of concern to an applicant whether it is of record or not, and applicant releases employers and persons named herein from any and all liability for any damages as a result of furnishing such information.The applicant agrees to furnish such additional information and complete such examinations as may be required to complete his/her employment file. It is agreed and understood that this application for employment in no way obligates the employer to employ the applicant. It is agreed and understood that if hired the employee may be on a probationary period during which time he/she may be discharged without recourse. I also understand that misrepresentation or omission of information or facts shall be considered an act of dishonesty and be sufficient cause for rejection or dismissal.I understand that as an applicant, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. It is further agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report including information regarding my character, general reputation, personal characteristics, and mode of living.It is understood that a job offer to an individual for paying to drive a CMV is contingent upon the person successfully passing the required DOT physical examination and drug test, and completing the Company's orientation program and hiring process. Applicants successfully completing the hiring process will be hired on the date he or she is dispatched on the first shipment or trip. 

Request for information from previous employer:
Nameyour full name
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Signature
(Sign Here)
Clear Signature
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Section 5: Certification of Self Employment
I certify as true that during this period I was self-employed:
Start Dateof appointment
End Dateof appointment
Type of Businessfull name
DOT Numberfull name
Name of Businessfull name
Address of Businessfull name
City:full name
Statefull name
Zip Codefull name
Notary Namefull name
Notary Date (MM/DD/YYYY):full name
Notary Statefull name
Business References:
Reference 1: Namefull name8
Reference 1: Phone Numberfull name
Reference 2: Namefull name
Reference 2: Phone Numberfull name
My Business / Public Liability Insurance was provided by:
Name of Carrierfull name
Phonefull name
Agent Namefull name
Addressfull name
Cityfull name
Statefull name
Zip Codefull name
Policy Numberfull name
Policy Numberfull name
Coverage Limitfull name
Namefull name
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Section 6: Commercial Motor Vehicle Driver Certification
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 applies to every driver who operates a commercial motor vehicle in intrastate, interstate, or foreign commerce. Commercial motor vehicle means a motor vehicle or combination of motor vehicles used to transport passengers or property that has a gross combination weight rating of 26,001 pounds or more inclusive of a towed unit with a gross vehicle weight rating of more than 10,001 pounds; or has a gross vehicle weight rating of 26,001 or more pounds; or is designed to transport 16 or more passengers, including the driver; or is of any size and is used in the transportation of hazardous material that require placarding as defined under Part 383. The requirements in Part 391 applies to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, including the driver, or transport hazardous materials that require placarding. DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations Contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows: 1. You, as a commercial motor vehicle driver, may not possess more than one license. 2. Sections 383.31 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it to your employing motor carrier and that state that issued your license within 30 days.

The following License is the only one I will and do possess:

Drivers' License Numbertrue
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Statetrue
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License Expirationof appointment
date_range
Full Namefull name
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Section 7: Motor Vehicle Driver's Records
Eastex Crude Trucking, LLC
Certification of Violations / Annual Review of Driving Record
Driver Nametrue
Date of Birth
Driver License #full name
State

REQUIRED: Each Driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 3 Years.

Datetrue
Offensetrue
Locationtrue
Type of Vehicle Operatedfull name
Datefull name
Offensefull name
Locationfull name
Type of Vehicle Operatedfull name
Datefull name
Offensefull name
Locationfull name
Type of Vehicle Operatedfull name
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Section 8: Criminal Background Check
Full Nametrue
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Other Names Used:full name8
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Current Address:true
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City:true
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Statetrue
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Zip Codetrue
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Eastex Crude Trucking, LLC will be requesting your social security number (SSN) in order to expedite this check with the iiX company. Your SSN will not be disclosed to anyone outside Eastex Crude Trucking, LLC except as mandated by law.

Driver's License #true
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State of Issue
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Date of Birth
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In connection with my employment at Eastex Crude Trucking, LLC, I hereby authorize the iiX Company to conduct a security background check on me. I understand that this security check will cover information such as criminal history, education, employment, and professional licensee/certifications. I understand that this background check may include information from previous employers relating to my work experience. I hereby release Eastex Crude Trucking, LLC and its employees, as well as iiX company and its employees, from all liability resulting from furnishing of this information to Eastex Crude Trucking, LLC. I certify that the statements made by me on this form are true, complete, and correct to the best of my knowledge and belief, and made in good faith. I understand that any false statements made herein could void my consideration for employment, or could result in disciplinary action up to, and including termination. With few exceptions, you are entitled (at your request) to be informed about the information Eastex Crude Trucking, LLC collects about you. Under Section 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under Section 559.004 of the Texas Government Code, you are entitled to have Eastex Crude Trucking, LLC correct information about you that is held by us and is incorrect. The information that Eastex Crude Trucking, LLC collects will be retained and maintained as required by Texas records retention laws (Section 441.180 et seq. Of the Texas Government Code) and rules. Different types of information are kept for different periods of time.
Date
date_range
SignatureI agree to the terms and conditions
(Sign Here)
Clear Signature
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Section 9: Alcohol and Drug Test Statement
Full Nametrue
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Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, orrefused to test, on any pre-employment drug or alcohol test administered by an employer to which theemployee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drugand alcohol testing rules during the past two years. If the employee admits that he or she had a positivetest or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, untiland unless the employee documents successful completion of the return-to-duty process. (see Sec.40.25(b)(5) and (e))

The prospective employee is required by Sec. 40.25(j) to respond to the following:

Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?
If you answered yes, can you provide / obtain proof that you’ve successfully completed the DOT return-to-duty requirements?
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