First Name*
Last Name*
Email Address*
Phone*
Do you have a valid Commercial Driver's License?
No answer Yes No
Are you 18 years of age or older?
No answer Yes No
Have you ever been convicted of a felony?
No answer No Yes
If “Yes”, you have been convicted of a felony, please explain the circumstances around the conviction:
Are you related to any current NCL employee?
Yes No
Highest level of education*
If you have not lived at your current address for at least 3 years, please complete the following information regarding your previous address. North Coast Logistics requires at least the last 3 years of addresses.
Previous Address Street Name, City, State, Zip Code, # of Years at Address*
Previous Address Street Name, City, State, Zip Code, # of Years at 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.*
Current License Held:
STATE LICENSE # TYPE/CLASS ENDORSEMENTS EXPIRATION DATE*
Previous License Held:
STATE LICENSE # TYPE/CLASS ENDORSEMENTS EXPIRATION DATE*
DRIVING EXPERIENCE -
Please list the Equipment Class
Straight Truck
Tractor and Semi-Trailer
Tractor and 2 Trailers
Tractor and Tanker
Other
The type of Equipment
Van
Tank
Flat
Other
The Dates that you drove them and the approximate total number of miles driven for each.
ACCIDENT RECORD FOR THE PAST 3 YEARS
Please list any accidents that you have had in the past 3 years.
Please include:
Date(most recent first)
Nature of the accident- Head-on, rear-ended, etc.
Number of fatalities, if any
Number of injuries, if any
Was a chemical spill involved*
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
Please include:
Date of conviction or forfeiture
Violation
State the violation occurred in
Penalty, if any
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.
Name, Address and Phone Number of current or most recent employer*
Dates of Employment*
Position Held*
Reason for leaving*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*
-- No answer -- 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 CFR, part 40?*
-- No answer -- Yes No
Name, Address and Phone Number of previous employer
Dates of Employment
Position Held
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? **
-- No answer -- 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 CFR, part 40? **
-- No answer -- Yes No
Name, Address and Phone Number of previous employer
Dates of Employment
Position Held
Reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations? **
-- No answer -- 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 CFR, part 40? **
-- No answer -- Yes No
Please explain any gaps in employment(include month/year and reason)*
APPLICANT STATEMENT
I certify that the information on this application and its supporting documents are accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employed if discovered later.
I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant for consideration of employment on any basis prohibited by applicable local, state, or federal law.
I authorize North Coast Logistics, Inc to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a criminal and credit background investigation, driving record investigation, and/or screening for illegal substances upon a conditional offer of employment.
I understand that this document is not an offer of employment, and that an offer of employment, if tendered, does not constitute a contract for continued guaranteed employment. I understand that North Coast Logistics, Inc is an at-will employer and the employment relationship may be terminated at any time by either party, for any or no reason, other than a reason prohibited by law.
If employed, I will be required to furnish proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete and I-9 form in this regard.*
Yes, I certify that I have read, fully understand, and accept all terms of this forgoing applicant statement. No, I do not certify that I have read, fully understand, and accept all terms of this forgoing applicant statement.
RELEASE OF INFORMATION AUTHORIZATION
Please read and acknowledge the form in the space provided below. Your written authorization is necessary for completion of the application process.
I hereby authorize North Coast Logistics, Inc. to investigate my background and qualifications for purposed of evaluating whether I am a qualified for the position for which I am applying. I understand that North Coast Logistics, Inc. may utilize an outside firm or firms to assist in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company’s choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not be processed further.
Please type your full name below as authorization.*
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, if the previous employer(s) and I cannot agree on the accuracy of the information.
This certifies that I 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.
Applicant Signature-By typing my name and date below I am agreeing that this is my electronic signature.*
POLICY STATEMENT AND AGREEMENT
In accordance with the department of transportation’s requirements of the Federal Motor Carrier Safety Regulation part 382
and as a part of North Coast Logistics, Inc. substance abuse policy I hereby acknowledge the following:
A) I understand and acknowledge the rules and regulations regarding controlled substances and alcohol misuse.
B) I agree and will willingly submit to any substance or alcohol test as required by the above guidelines.
C) It is understood that testing can be done for any of the following reasons:
1. Pre-employment
2. Post-employment
3. Random
4. Reasonable suspicion
5. Bi-annual
6. Return to duty
7. Follow up testing
Applicant Signature-By typing my name and date below I am agreeing that this is my electronic signature. **
POLICY STATEMENT AND AGREEMENT
It is the policy of North Coast Logistics, Inc., that neither illegal drugs nor alcohol abuse shall be tolerated by any employee or
management of this company. The policy is for the protection of the employee, the company and the general public. Under no
circumstances will the use or possession of illegal drugs be allowed. Any knowledge of a fellow employee violating this policy shall
be immediately brought to the attention of a supervisor. Any admission of possession or use of illegal drugs will be kept in the
strictest confidentiality. All testing for controlled substances or alcohol shall follow the proper rules and regulations set for by the
DOT. This policy is in accordance with rule 382.601 of the Federal Motor Carrier Safety Sensitive functions. Each individual
employee is welcome to obtain more information about alcohol and controlled substances.
Any reference or inquiry to the above information should be addressed to Safety Director, North Coast Logistics, Inc.
Applicant Signature-By typing my name and date below I am agreeing that this is my electronic signature. * **