Ashe County Transportation Authority EMPLOYMENT APPLICATION – Make sure you answer all fields with required information. ← BackThank you for your response. ✨ PLEASE READ COMPLETELYThe information requested on this form is required by federal law (49 CFR) to be provided by any driver applying for a commercial driver position as defined in 49 CFR 390.5. Failure to complete required areas can place both the applicant and carrier in violation of federal law. Information provided will be verified by carrier as required under various parts of 49 CFR, including Part 382 and Part 391.If unsure of question or require help with competing form please ask carrier representative.Name(required) Social Security No.:(required) Date of Birth: (YYYY-MM-DD)(required) Document Presented to Verify Age:(required) Mobile Phone:(required) Home Phone: Email Address:(required) Current Street Address:(required) City, State, Zip:(required) How long have you lived there? years/months(required) Current Mailing Address:(required) City, State, Zip:(required) Previous Address (If less than 3 years) #1:Street, City, State, Zip(required) How long did you lived there? years/months(required) Previous Address (If less than 3 years) #1:Street, City, State, Zip(required) How long did you lived there? years/months(required) Previous Address (If less than 3 years) #1:Street, City, State, Zip(required) How long did you lived there? years/months(required) Are you legally authorized to work in the United States as a commercial driver under 49 CFR? Yes/No(required) Have you ever been convicted of a felony? Yes/No(required) If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.(required) Is there any reason you might be unable to perform the functions of the job for which you have applied? Are you applying for ADA consideration?(required) What position(s) are you applying for? (Driver / Office / Maintenance / Management) (required) What type of work will you accept? (Permanent Full time / Permanent Part time)(required) What is the earliest date you can begin work?(required) Are you a veteran? Yes/No(required) EDUCATION: Highest grade you have completed? 1 2 3 4 5 6 7 8 9 10 11 12 GED College 1 2 3 4(required) High School attended?(required) Graduate? Yes/No(required) Type of Degree?(required) College/University attended?(required) Graduate? Yes/No(required) Type of Degree?(required) List Mechanical Skills or Experience(required) If the position(s) applied for require specific courses, indicate those courses completed and credits received:(required) Have you had experience driving in adverse weather? Yes/No (required) List skills/experience you have? (Back vehicle using mirror, Manual Shift, Defensive Driving, Other)(required) References – Name / Address / Relationship / Phone Number(required) References – Name / Address / Relationship / Phone Number(required) References – Name / Address / Relationship / Phone Number(required) EMPLOYMENT HISTORYAll applicants must provide the following information for any previous employer during the preceding 3 years. Complete all areas below. Applicants shall also provide an additional 7 years of information for those employers for whom the applicant has operated a commercial motor vehicle (CMV).Current Employer (Company Name, Address, City, State, Zip, Phone Number, Contact Person)(required) Dates – From: Month/Year To: Month/Year(required) Position Held(required) Salary/Wage(required) Reason for Leaving:(required) Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug & Alcohol Testing requirements of 49 CFR Part 40?:(required) Previous Employer (Company Name, Address, City, State, Zip, Phone Number, Contact Person)(required) Dates – From: Month/Year To: Month/Year(required) Position Held(required) Salary/Wage(required) Reason for Leaving:(required) Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug & Alcohol Testing requirements of 49 CFR Part 40?:(required) Previous Employer (Company Name, Address, City, State, Zip, Phone Number, Contact Person) Dates – From: Month/Year To: Month/Year Position Held Salary/Wage Reason for Leaving: Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug & Alcohol Testing requirements of 49 CFR Part 40?: Previous Employer (Company Name, Address, City, State, Zip, Phone Number, Contact Person) Dates – From: Month/Year To: Month/Year Position Held Salary/Wage Reason for Leaving: Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug & Alcohol Testing requirements of 49 CFR Part 40?: Previous Employer (Company Name, Address, City, State, Zip, Phone Number, Contact Person) Dates – From: Month/Year To: Month/Year Position Held Salary/Wage Reason for Leaving: Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug & Alcohol Testing requirements of 49 CFR Part 40?: ACCIDENT RECORDProvide the following information for any accident your were involved in during the preceding 3 years. If none, type N/A.Date of last accident / Nature of Accident (required) Fatalities / Injuries / Hazardous Materials Spill(required) Date of next previous accident / Nature of Accident (required) Fatalities / Injuries / Hazardous Materials Spill(required) Date of next previous accident / Nature of Accident (required) Fatalities / Injuries / Hazardous Materials Spill(required) TRAFFIC CONVICTIONSPROVIDE THE FOLLOWING INFORMATION FOR ALL MOTOR VEHICLE VIOLATIONS FOR WHICH YOU WERE CONVICTED OR PLED GUILTY TO DURING THE PRECEDING 3 YEARS (DO NOT INCLUDE PARKING TICKETS) (IF NONE, WRITE, NONE)Location, Date, Charge, Penalty(required) Location, Date, Charge, Penalty(required) Location, Date, Charge, Penalty(required) EXPERIENCE AND QUALIFICATIONS – DRIVERList all driver licenses or permits held in the past 3 years:#1 – State, License No, Type, Expiration Date(required) #2- State, License No, Type, Expiration Date #3- State, License No, Type, Expiration Date Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes/No(required) Has any license, permit or privilege ever been suspended or revoked? Yes/No(required) IF THE ANSWER TO EITHER QUESTION IS YES, GIVE DETAILS DRIVING EXPERIENCEWhat types of vehicles do you have experience driving? (van, bus, tank, flat, dump truck, straight, tractor trailer:(required) List states you have operated in for the last 5 years:(required) DRUG & ALCOHOL INFORMATIONIn the previous three (3) years have you:1. Violated the Alcohol and Control Substance prohibitions under subpart B of 49CFR Part 382 or 49CFR Part 40? Yes/No(required) 2. Failed to undertake or complete a rehabilitation program prescribed by a SAP pursuant to 49CFR 382.605?(required) 3. I had an alcohol test result of 0.04 or higher? Yes/No(required) 4. I had a Verified Positive Drug Test? Yes/No(required) 5. I refused to test (including verified adulterated or substituted drug test result)? Yes/No(required) TO BE READ AND SIGNED BY APPLICANTThis certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge: (By inputting my name in the box, I agree.)Name(required) Date(required) Attachment AApplicants Authorization to Obtain past Drug and Alcohol Test ResultsI, (insert name)(required) understand that as a condition of the hiring process of Ashe County Transportation Authority (ACTA), I must give ACTA written permission to receive results of all DOT – required drug and/or alcohol tests (including any refusals to be tested) from ALL of the companies that I have worked as a driver, or I took a preemployment drug and/or alcohol test, during the past three (3) years. I also authorize ACTA to contact and receive results from any consortium that represents the companies that I worked for or applied to. I understand that my signing of this authorization does not guarantee that I will be offered a position with ACTA.Listed below are ALL the companies for which I worked as a driver, or to which I applied as a driver during the past three (3) years. I authorize ACT A to obtain from those companies, and I authorize those companies to furnish ACT A with the following information concerning my drug and alcohol tests: (I) all positive drug test results during the past two three (3);(II) all alcohol test results of 0.04 or greater during the past three (3) years; (Ill) all alcohol test results of 0.02 or greater but less than 0.04 during the past three (3) years; (IV) all instances in which I refused to submit to a DOT – required drug and/or alcohol test during the past three (3) years.The following is a list of ALL the companies for which I worked as a driver, or to which I applied for work as a driver, during the past three (3) years. (If NONE, put none)#1 Company Name / Mailing Address / Supervisor / Phone # / Dates Worked(required) #2 Company Name / Mailing Address / Supervisor / Phone # / Dates Worked #3 Company Name / Mailing Address / Supervisor / Phone # / Dates Worked #4 Company Name / Mailing Address / Supervisor / Phone # / Dates Worked I have read and understand this authorization to release my past drug and alcohol test results. I certify that all the information, which I have furnished, on this form is true and complete, and that I have identified ALL of the companies for which I have either worked, or applied for work , as a driver during the past two (2) years. (By inputting my name in the box, I agree.)Name(required) Date(required) Social Security Number(required) Date of Birth(required) ATTACHMENT BWOLFE REALITY CHECK CONSUMER REPORT and INVESTIGATIVE CONSUMER REPORT DISCLOSURE (FOR EMPLOYMENT PURPOSES)In connection with your employment or application for employment (including contract for services) and continued employment with us and in accordance with applicable laws, a consumer reprinting agency (“Agency”) may obtain or assemble consumer reports and/or investigative consumer reports (collectively, “Reports”) which may include information about you related to previous employment (including employers, dates of employment, salary information, reasons for termination, etc.), accident history, academic history, verification of references and other information supplied by applicant, professional credentials, drug/alcohol use in violation of law and/or company policy, driving record, worker’s compensation claims, criminal history records, information about your character, general reputation, personal characteristics and mode of living (collectively, “Information”). Information may be obtained from government agencies, educational institutions, Agency clients, personal references, personal interviews and other information suppliers (collectively. ”Suppliers”), and any report of an interview between the Agency and you.PART I -AUTHORIZATION FOR RELEASE OF INFORMATION (FOR EMPLOYMENT PURPOSES)I hereby authorize Agency to receive information and disclose such information to its customers for the purpose of making a determination as to my eligibility for employment, promotion, retention or other lawful purpose. If hired or contracted, I authorize Agency and to retain this document on file to act as ongoing authorization for the procurement and possession of Reports at any time during my employment or contract period. I fully release Agency and Suppliers from all claims of damages related to the investigation of my background and provision of information as set forth in this disclosure and authorization. I agree that information in Agency’s possession may be supplied by Agency for legally permissible purposes; provided, such information will not include the Drug and Alcohol information set forth above, unless I have given a separate specific consent for Agency to share such information.By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and folly understand this disclosure and authorization for release; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; (vi) I authorize Agency and any person or entity contacted by Agency to furnish the above mentioned information; and (vii) facsimile or photographic copies of this authorization are as valid as the original.I understand that if I do not consent, any offer of my employment or contract will be withdrawn. If hired failure to cooperate with you or Agency regarding a current or future report will be cause to terminate my employment or contract. (By inputting my name in the box, I agree.)LEGAL FULL Name(required) Date of Birth(required) Social Security Number(required) Full Street Address(required) Driver’s License No.:(required) State Issued(required) Today’s Date:(required) SUBMITSubmitting form Δ
