APPLICATION
Company Peck Trucking____________
Address 415 South 600 East______________________________
City Lehi_________________ State __Utah
Zip Code __84043
The purpose of this
application is to determine whether or not the applicant is qualified to operate
motor carrier equipment according to the requirements of the Federal Motor
Carrier Safety Regulations and the Company named above.
Instructions to Applicant
____________________________________________________________________________________
Please answer all questions. If the answer to any question is "No" or "None", do not leave the item blank, but write "No" or "None".
Date _______________ Position applying for; Check One: Driver _____ Mechanic_____ Mining_____
Name _______________________________________________________________________________
(first) (middle) (last)
Home Phone number (_____) _____________________ Cell Phone Number (____)________________
In Case of an Emergency Call ________________________ Phone Number (____)________________
*Age ______ Date of Birth _______________
*The Age Discrimination of
Employment Act of 1967 prohibits discrimination of the basis of age with
respect to individuals who are at least 40 but less than 70 years of age.
Physical Exam Expiration Date: ________________________________
Current & Three Years Previous Addresses:
_________________________________________________________From ___________ To__________
________________________________________________________ From ___________ To __________
________________________________________________________ From ___________ To __________
________________________________________________________ From ___________ To __________
Have you worked for this company before? Yes________ No ________
If yes, give dates: From _____________ To___________
Reason for Leaving? _____________________________________________________________________
Education History
______________________________________________________________________________
Highest grade completed: High School:__________ College: ____________Post-Graduate:___________
Employment History
______________________________________________________________________________
Give a Complete Record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past ten years.
Mo/Yr Mo/Yr Present or Last Employer
From _______________ To _______________ Name _________________________________________
Position Held___________________________ Address ________________________________________
Reason for Leaving ______________________ Phone # (______)______________ Salary_____________
Where you subject to the
FMCSRs* while employed here? Yes ________ No _______
Was your job designated as a
safety-sensitive function in any DOT-Regulated mode subject to the drug and
alcohol testing requirements of 49 CFR Part 40? Yes _______ No _______
Mo/Yr Mo/Yr Present or Last Employer
From _______________ To _______________ Name _________________________________________
Position Held___________________________ Address ________________________________________
Reason for Leaving ______________________ Phone # (______)______________ Salary_____________
Where you subject to the FMCSRs*
while employed here? Yes ________ No _______
Was your job designated as a
safety-sensitive function in any DOT-Regulated mode subject to the drug and
alcohol testing requirements of 49 CFR Part 40? Yes _______ No _______
Mo/Yr Mo/Yr Present or Last Employer
From _______________ To _______________ Name _________________________________________
Position Held___________________________ Address ________________________________________
Reason for Leaving ______________________ Phone # (______)______________ Salary_____________
Where you subject to the
FMCSRs* while employed here? Yes ________ No _______
Was your job designated as a
safety-sensitive function in any DOT-Regulated mode subject to the drug and
alcohol testing requirements of 49 CFR Part 40? Yes _______ No _______
Mo/Yr Mo/Yr Present or Last Employer
From _______________ To _______________ Name _________________________________________
Position Held___________________________ Address ________________________________________
Reason for Leaving ______________________ Phone # (______)______________ Salary_____________
Where you subject to the
FMCSRs* while employed here? Yes ________ No _______
Was your job designated as a
safety-sensitive function in any DOT-Regulated mode subject to the drug and
alcohol testing requirements of 49 CFR Part 40? Yes _______ No _______
Mo/Yr Mo/Yr Present or Last Employer
From _______________ To _______________ Name _________________________________________
Position Held___________________________ Address ________________________________________
Reason for Leaving ______________________ Phone # (______)______________ Salary_____________
Where you subject to the
FMCSRs* while employed here? Yes ________ No _______
Was your job designated as a
safety-sensitive function in any DOT-Regulated mode subject to the drug and
alcohol testing requirements of 49 CFR Part 40? Yes _______ No _______
*The Federal Motor Carrier
Safety Regulations (FMCSRs*) apply
to anyone who operates a motor vehicle on a highway in interstate commerce to
transport passengers or property when the vehicle: (1)has a GVWR or weighs
10,001 pounds or more, ( 2) is designed or used to transport nine or more
passengers, or (3) is of
any size, used to transport hazardous materials in a quantity requiring
placarding.
Driving Experience
________________________________________________________________________
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Class of
Equipment |
Dates |
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Approximate
Number of Miles (Total) |
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From |
To |
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Straight
Truck |
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Tractor
and Semi-trailer |
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Tractor-Two
Trailers |
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Tractor-three
Trailers (triples) |
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Other |
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List states operated in, for the last five years: ________________________________________
______________________________________________________________________
List special courses/training completed (PTD/DDC, Haz Mat,
ect.): _________________________
List any Safe Driving Awards you hold and from whom: ______________________________________
Accident Record for past three years (attach sheet if
more space is needed)
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Date of
Accident |
Nature of accidents (Head on,
rear end, upset, ect.) |
Location
of Accident |
# of
Fatalities |
# of
people Injured |
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Traffic Convictions and Forfeitures for the last three
years (other than parking violations)
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Date |
Location |
Charge |
Penalty |
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A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes ____ No ____
B. Has any license, permit or privilege ever been suspended or revoked? Yes ____ No ____
C. Is there any reason you might be unable to perform the functions of the job for which
You have applied (as described in the job description)? Yes ___ No ____
D. Have you ever been convicted of a felony? Yes ___ No ____
If the answers to A,B,C or D is "Yes", give details ________________________________________________
_________________________________________________________________________________________
Personal References
__________________________________________________________________________
List three personal references, other than family members,
who have knowledge of your safety habits.
Name ___________________________Address _____________________Phone ______________________
Name ___________________________Address _____________________Phone ______________________
Name ___________________________Address
_____________________Phone ______________________