Driver Application - Tom Gullickson, Inc.

DRIVER’S RIGHTS TO REVIEW BACKGROUND CHECK – Dear Applicant: Per FMCSR 391.21(d) Before an application is submitted, the motor carrier shall inform the applicant that the information he/she provides for the work history may be used, and the applicant’s prior employers may be contacted, for the purpose of investigating the applicant’s safety performance history information. The prospective motor carrier must also notify the driver in writing of his/her due process rights as specified in § 391.23(i) regarding information received as a result of these investigations. You the applicant have the following rights: (i) The right to review information provided by previous employers; (ii) The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective motor carrier; (iii) The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

TG Driver Employment

Step 1 of 9

Name(Required)

First Last

Phone(Required)

Email(Required)

Enter Email Confirm Email

Current Address(Required)

Street Address Address Line 2 City State ZIP Code

Years At Current Address(Required)

If at the above residence less than 3 years, list below all residences for the past 3 years.

Date of Birth(Required)

Social Security Number(Required)

In Case Of Emergency Notify(Required)

Phone(Required)

Have you ever applied with this company before?(Required)

Yes

If yes, when?

Have you ever worked for this company under another name?(Required)

Yes

If yes, the Name?

Are you applying as a (Check appropriate)(Required)

Company driver or an

Owner operator?

Are you currently employed?(Required)

Yes

If not, how long since leaving last employment?

Date you are available to start work?(Required)

How long are willing to be away from home?(Required)

How much home time will you need when you return?(Required)

How many miles or hours are you expecting per week?(Required)

How much do you expect to make per week (gross)?(Required)

Have you ever been convicted of a crime?(Required)

Yes

(A conviction does not automatically bar you from employment)

Any pending charges against you?(Required)

Yes

(Explain below if necessary)

If yes, explain for each entry: 1) Is it a conviction or pending charge? 2) Date of conviction or upcoming hearing, and 3) State in which convicted/charged.(Required)

EDUCATION

Choose highest grade level completed(Required)

College(Required)

Last School Attended(Required)

Address(Required)

List special courses or training that will help you as a driver

Accident Review for past 3 years:

Motor Vehicle Laws & Ordinance Violations: for the past 3 years other than parking violation

Consent(Required)

I agree to the following statement

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty and reason for non-consideration or subsequent dismissal if hired or denial of authorization to drive. It is also agreed and understood that the motor carrier and his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his/her furnishing such information.

I understand that nothing contained in this application or in the granting of any interview or a road test is intended to create an employment contract between this company and myself, for either employment, authorization to drive, or for the providing of any benefits. I agree to furnish such additional information that may be necessary and complete such examinations as may be required to complete my application file including but not limited to a pre-employment negative urine test and successful completion of a human performance evaluation including a Department of Transportation Physical. No promises regarding employment or authorization to drive have been made to me, and no such promises exist unless specifically made by this Company in writing. It is agreed and understood that if qualified, hired, or contract started, I may be on a probationary period during which time I may be disqualified without recourse. I understand employment or authorization to drive with this carrier is on an “at-will” basis that allows me to quit, be fired, or lease agreement revoked at any time with or without notice and with or without cause. This 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.

TG Driver Employment

EDUCATION

EMPLOYMENT RECORD

DRIVER EXPERIENCE & QUALIFICATION

Accident Review for past 3 years:

Motor Vehicle Laws & Ordinance Violations: for the past 3 years other than parking violation

accurate

on-time

reliable

safety focused