INSTRUCTIONS

Phone: 763-441-0047
Fax: 763-441-4550
Toll Free: 800-894-7981
www.novcotrucking.com

11090 173rd Ave NW
Elk River, MN 55330



APPLICATION FOR EMPLOYMENT
COMMERCIAL DRIVER


INSTRUCTIONS


Thank you for applying to Novco. You will be asked about your employment history and some basic trucking knowledge questions. You will also be asked to sign releases for background checks, a request for check of driving records, and a Fair Credit Reporting Act Disclosure Statement.

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Novco Employment Application

Phone: 763-441-0047
Fax: 763-441-4550
Toll Free: 800-894-7981
www.novcotrucking.com

11090 173rd Ave NW
Elk River, MN 55330



APPLICATION FOR EMPLOYMENT
COMMERCIAL DRIVER


Applicant Name*
Date of Application*

TO BE READ AND SIGNED BY APPLICANT

I authorize Novco, Inc. to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision.  (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.)  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 understand, also, that I am required to abide by all rules and regulations of Novco, Inc.


I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49CFR 391.23(d) and (e).  I understand that I have the right to:


  • Review information provided by the employers;
  • Have error in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
  • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
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Date*

APPLICANT TO COMPLETE

(Answer all questions, fields marked with a red * are required.)

Full Name*
Date of Birth*
Current Address*
Previous Address 1 (Go back 3 years.)
Previous Address 2 (Go back 3 years.)
Can you legally be employed in the United States?*
Do you have Proof of Age?*
Have you ever been employed by this company before?*
Currently employed?*
May we contact your employer?
If there is any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding Three (3) years, complete mailing address, street number, city, state, and zip code.


Applicants to drive a commercial motor vehicle* intrastate or interstate commerce shall also provide an additional Seven (7) years information on those employers for whom the applicant operated such vehicles.


(Note:  List employers in reverse order starting with the most recent.)

EMPLOYER #1

From (month/year)
To (month/year)
Address
Were you subject to the FMCSR** while employed?
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug & Alcohol testing requirements of 49CFR Part 40?

EMPLOYER #2

From (month/year)
To (month/year)
Address
Were you subject to the FMCSR** while employed?
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug & Alcohol testing requirements of 49CFR Part 40?

EMPLOYER #3

From (month/year)
To (month/year)
Address
Were you subject to the FMCSR** while employed?
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug & Alcohol testing requirements of 49CFR Part 40?

EMPLOYER #4

From (month/year)
To (month/year)
Address
Were you subject to the FMCSR** while employed?
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug & Alcohol testing requirements of 49CFR Part 40?

EMPLOYER #5

From (month/year)
To (month/year)
Address
Were you subject to the FMCSR** while employed?
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug & Alcohol testing requirements of 49CFR Part 40?

LICENSE HELD #1

State
Expiration Date

LICENSE HELD #2

State
Expiration Date

EQUIPMENT EXPERIENCE AND KNOWLEDGE

TRUCKING KNOWLEDGE QUESTIONS

ACCIDENTS AND VIOLATIONS

ACCIDENTS IN THE PAST THREE (3) YEARS

(List most recent first – attach additional sheets if necessary)


Date of Accident 1
Injuries or Fatalities
Injuries or Fatalities
  NO YES
Injuries?
Fatalities?
Date of Accident 2
Injuries or Fatalities
Injuries or Fatalities
  NO YES
Injuries?
Fatalities?
Date of Accident 3
Injuries or Fatalities
Injuries or Fatalities
  NO YES
Injuries?
Fatalities?

TRAFFIC CONVICTIONS IN THE PAST THREE (3) YEARS

 (List most recent first – No parking violations)

Date of Traffic Conviction 1
Date of Traffic Conviction 2
Date of Traffic Conviction 3

EDUCATION AND TRAINING

Please provide the following information about completed education, starting with the most recent.

Graduate?
Date of Graduation (month/year)
Graduate?
Date of Graduation (month/year)
Graduate?
Date of Graduation (month/year)
Graduate?
Date of Graduation (month/year) - Copy
Have you ever served in the U.S. Military?

CERTIFICATIONS AND CREDENTIALS

U.S. Passport
U.S. Passport Expiration Date
TWIC Card
TWIC Card Expiration Date
DOT Physical
DOT Physical Expiration Date
AL Coil Certification
AL Coil Certification Expiration Date
Have you tested positive for a pre-employment or random Drug and Alcohol test in the past three years?
Have you ever had your license revoked or suspended?

Knowledge Questions


You have just scaled your load, your scale ticket reads as follows:

STEER AXLE:
11,800
DRIVE AXLE:
35,200
TRAILER AXLE:
32,800

GROSS WEIGHT:
79,800


Is this legal?

REFERENCES

Please provide three personal references. These references should not be people related to you or former supervisors.

Reference name and how long you've known them.
Reference name and how long you've known them.
Reference name and how long you've known them.

CAREFULLY READ THE FOLLOWING AND SIGN BELOW

By signing this statement, I certify that this employment application has been completed by me, and all of the entries provided are true, complete and accurate, to the best of my knowledge.  By signing below I also authorize Novco, Inc. to make such inquiries into my employment, financial, personal, or medical history as might be needed to make an employment decision.  I understand that inquiries into my medical history are generally made after a job offer is made.


I hereby release my former employers, healthcare providers and schools from any and all liability in making response to these inquiries and from releasing the requested information.

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Date of Application*

FOR COMPANY USE

Interview Notes:

Date
Date of Hire
Date to Start

REQUEST FOR CHECK OF DRIVING RECORD

I hereby authorize you to release the following information to Novco, Inc. for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations.  You are released from any and all liability, which may result from furnishing such information.

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Date*

In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), I hereby certify the following:

  1. The applicant has authorized in writing the procurement of this report
  2. The applicant has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes.
  3. The information requested below will be used for permissible purpose (i.e., information for employment purposes) and will be used for no other purpose.
  4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and 
  5. Before taking an adverse action based in whole or in part on the report the applicant will receive a copy of this requested report and the summary of consumer rights as provided with the report.

I also hereby certify that this report request and the above applicant’s release notice meet the definition of “permissible uses” of state motor vehicle records under the provision of the DRIVER'S PRIVACY PROTECTION ACT OF 1994 (public law 103-322, Title XXX, Section 30002(a)).

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Date - OFFICE USE ONLY

The information is requested from:

_______________________________________________________

_______________________________________________________

_______________________________________________________

To whom it may concern:

The person named below has sought employment with Novco, Inc. as a _________________________.

In accordance with the Federal Department of Transportation Regulations, Part 391;
Please provide the applicants driving record for the past three years.


DRIVER’S NAME____________________________________________________________________

ADDRESS:_________________________________________________________________________

CITY______________________________  STATE___________________  ZIP___________________

LICENSE #______________________________  STATE___________

SS#______________________________  DOB__________________


Information requested by: Novco, Inc. 11090 173rd Ave NW, Elk River, MN 55330

Name of Company Representative: _______________________________________   ________________

                                                         (Printed Name)                                                         (Title)


Signature of Novco, Inc. Representative: ____________________________________________________

AUTHORIZATION FOR RELEASE OF INFORMATION

Phone: 763-441-0047
Fax: 763-441-4550
Toll Free: 800-894-7981
www.novcotrucking.com

11090 173rd Ave NW
Elk River, MN 55330


I authorize Novco, Inc. to make such investigations and inquire of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision.  (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended).

I hereby authorize you to release the following information to Novco, Inc. for the purposes of investigation as required by Section 391.23 and 382.413 of the Federal Motor Carrier Safety Regulations.  I do hereby release the company supplying this information from all liability as a result of releasing truthful information in compliance with this request.

The information that I have authorized Novco, Inc. to review involves tests required by DOT. If any carrier (company and/or school) furnishes Novco, Inc. with information concerning items (1) through (6) above, I also authorize that carrier (company and/or school) to release and furnish the date of my negative drug and/or alcohol test and/or test results below .04 during the three (3) year period and the name and phone number of any substance abuse professional who evaluated me during the past three (3) years.

By signing below, I authorize, per 49 CFR Part 40, the release of information from my DOT regulated drug and alcohol testing records by carriers, companies and/or schools to Novco, Inc. I authorize the following information concerning DOT drug and alcohol testing violations, including pre-employment test during the past three (3) years; (1) alcohol test with a result of .04 or higher; (2) verified positive drug test; (3) refusals to be tested (including verified altered or substituted results; (4) other violations of DOT drug and alcohol testing regulations; (5) information obtained from previous employers of a drug and alcohol rule violation(s); and (6) documents, if any, of completion of a return-to-duty process following a rule violation

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Date*
Applicant's Name*

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

Phone: 763-441-0047
Fax: 763-441-4550
Toll Free: 800-894-7981
www.novcotrucking.com

11090 173rd Ave NW
Elk River, MN 55330



FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT


In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying you previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes.  These reports are required by Sections 382.413,, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

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Date
Applicant's Name*
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