In compliance with 49 CFR § 391.21, the following application shall be completed and signed by Operator prior to the operation of commercial motor vehicles on behalf of Ship Connex, LLC, a federally registered motor carrier with office located at 1700 Enterprise Blvd Ste C, West Sacramento, CA 95691.
Operator is hereby notified, pursuant to 49 CFR § 391.23, that the information provided in this application will be used by Ship Connex, LLC to make inquiries to each State where Operator held or holds a commercial driver's license and to contact motor carriers for whom Operator rendered services in the past 10 years for the purpose of investigating Operator's safety performance history. Operator has the following rights regarding the information provided to Ship Connex, LLC. By other motor carriers:
(1 )The right to review such information;
(2)The right to have errors in the information corrected by the motor carrier who provided it and re-sent to Ship Connex, LLC.;
(3)The right to have a rebuttal statement attached to the alleged erroneous information, if the motor carrier and Operator cannot agree on the accuracy of the information.

Driver's Identification

Your Name (required)

Your Address (required)

Date of Birth

Social Security #

Physical Exam Expiration Date

Your Email (required)

Telephone Number

Have You Ever Worked For Us?
Yes No 

If Yes, Dates From-To
From: Until:

Reasons For Leaving?

Previous Addresses

List of addresses of residency for the past 3 years below

Address:

Address:

Address:

Driver's License

List each unexpired Commercial Driver License or Commercial Learning Permit (CLP)that has been issued to you:

CDUCPL #

State

Ex. Date

Class

Endorsements

Driving Experience

State your previous experience in the operation of motor vehicles:

Trucks

Date From

Date To

Apx. # of Miles

Truck-Tractor

Date From

Date To

Apx. # of Miles

Semi Full-Trailer

Date From

Date To

Apx. # of Miles

Other Information

List states operated in the last 5 years

List driving courses if any (PTD/DDC, Haz Mat, etc.):

List safe driving awards if any:

Accident Record

List of all motor vehicle accidents in which you were involved during the past 3 years:

Nature of Accident

Location

Date

Fatalities

Injuries

Record of Violations

List all violations of motor vehicle laws (other those involving only parking) of which you were convicted or forfeited bond or collateral during the past 3 years:

Offense

Date of Conviction

Locations

Type of Vehicle

Penalty

Denial, Revocation Or Suspension Of Driver's License/Permit

A. Have you ever been denied a license, permit or privilege to operate a commercial motor vehicle?  Yes No

Explain:

B. Has you ever had a license, permit or privilege to operate a commercial motor vehicle suspended or revoked?  Yes No

Explain:

C. Is there any reason you might be unable to perform the functions of the job for which you have applied?  Yes No

Explain:

D. Are you taking any medications which will limit your ability to drive?  Yes No

Explain:

E. Have you ever been convicted of a felony?  Yes No

Explain:

Previous Results For Controlled Substances Tests

CFR Part 40.25(j) requires the employer to ask any applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past tvw years. if the potential employee admits that he or she had a positive test or refusal to test, we must not use the employee to perform safety- sensitive functions, until and unless the potential employee provides documentation of successful completion of the return-to-duty process (See Section 40.25(b)(5) and (e)).
In the past two years, have you been:

A. Obtained verified positive results for controlled substance tests required by other companies?  Yes No

B. Obtained alcohol tests results indicating 0.04 or higher alcohol concentration?  Yes No

C. Refused to undergo alcohol or controlled substance testing required by other companies?  Yes No

If you answered "yes" to any of the questions above, provide the following information about the Substance Abuse Professional (SAP) that you consulted:

Name of SAP:

Address:

Telephone: Dates Visited:

Education and Employment History

Select the highest grade completed:
Grad School 1-12 College 1-4 Post Grad 1-4 

Previous Contracts With Motor Carriers

Give a complete record of all employment for the past three (3) years, including any unemployment or self- employment and all commercial driving experience for the past ten (10) years.

LAST CONTRACT

Motor carrier's name

Address

Phone Fax

Dates to -

Reasons For Leaving

Were 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 am alcohol testing requirement of 49 CFR Part 40?  Yes No

LAST CONTRACT

Motor carrier's name

Address

Phone Fax

Dates to -

Reasons For Leaving

Were 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 am alcohol testing requirement of 49 CFR Part 40?  Yes No

LAST CONTRACT

Motor carrier's name

Address

Phone Fax

Dates to -

Reasons For Leaving

Were 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 am alcohol testing requirement of 49 CFR Part 40?  Yes No

Certification

391 .23(i)(1) The prospective employer must expressly notify drivers with Department of Transportation regulated employment during the preceding three years-via the application form or other written document prior to any hiring decision-that he or she has the following rights regarding the investigative information that will be provided to the prospective employer pursuant to paragraphs (d) and (e) of this section:
(i)(1)(i) The right to review information provided by previous employers;
(i)(1)(ii) The right to have errors in the infonnation corrected by theuprevious employer and for that previous employe to re-send the corrected information to the prospective employer;
(i)(1)(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 infonnation.
(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business days deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making then available, the prospective motor carrier may consider the driver to have waived his/her request to review the records Visit www.fmcsa.dot.gov to review the regulations.
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.

Date:

Print Name: