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Employment Application
Contact Us
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Employment Application
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Employment Application
Contact Us
Privacy Policy
CALL TODAY – 1-800-251-5555
Online Application
Step
1
of
17
5%
Driver Employment Application
Flowerwood Management Inc.
(d/b/a/ Flowerwood Trucking)
15315 Kelly Rd
Loxley, AL 36551
Application Date
*
MM slash DD slash YYYY
Position Applied For:
*
Name
*
First
Middle
Last
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Must list all addresses for the past 3 years:
Current Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Do you need to add additional addresses?
*
Yes
No
Previous Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Previous Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Previous Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Previous Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employment History
ALL DRIVER APPLICANTS:
To drive in interstate commerce, you must provide the following information on all former/current employers (driving positions and non-driving positions) for the last 3 years. All information must be complete for your application to be considered.
ALL DRIVER APPLICANTS:
To be employed as a driver of a commercial motor vehicle (any vehicle requiring a CDL License) in intrastate or interstate commerce, you must also provide an additional 7 years information on those employers for whom you worked as a driver operating a commercial motor vehicle.
In other words, if you are going to drive a vehicle requiring a CDL, YOU MUST HAVE 10 YEARS working & driving experience (no gaps).
Current or Last Employer
Company Name
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Person
*
Contact Phone Number
*
Date Started
*
MM slash DD slash YYYY
Date Ended
*
MM slash DD slash YYYY
Position Held
*
Salary/Wage
*
Reason for Leaving
*
Were you subject to DOT rules while employed with this company?
*
Yes
No
While employed by this company, was your job designated as “safety-sensitive,” making you subject to the DOT drug and alcohol testing requirements?
*
Yes
No
Do you have additional employers to add?
*
Yes
No
Previous Employer
Company Name
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Person
*
Contact Phone Number
*
Date Started
*
MM slash DD slash YYYY
Date Ended
*
MM slash DD slash YYYY
Position Held
*
Salary/Wage
*
Reason for Leaving
*
Were you subject to DOT rules while employed with this company?
*
Yes
No
While employed by this company, was your job designated as “safety-sensitive,” making you subject to the DOT drug and alcohol testing requirements?
*
Yes
No
Do you have additional employers to add?
*
Yes
No
Previous Employer
Company Name
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Person
*
Contact Phone Number
*
Date Started
*
MM slash DD slash YYYY
Date Ended
*
MM slash DD slash YYYY
Position Held
*
Salary/Wage
*
Reason for Leaving
*
Were you subject to DOT rules while employed with this company?
*
Yes
No
While employed by this company, was your job designated as “safety-sensitive,” making you subject to the DOT drug and alcohol testing requirements?
*
Yes
No
Do you have additional employers to add?
*
Yes
No
Previous Employer
Company Name
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Person
*
Contact Phone Number
*
Date Started
*
MM slash DD slash YYYY
Date Ended
*
MM slash DD slash YYYY
Position Held
*
Salary/Wage
*
Reason for Leaving
*
Were you subject to DOT rules while employed with this company?
*
Yes
No
While employed by this company, was your job designated as “safety-sensitive,” making you subject to the DOT drug and alcohol testing requirements?
*
Yes
No
Do you have additional employers to add?4
*
Yes
No
Previous Employer
Company Name
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Person
*
Contact Phone Number
*
Date Started
*
MM slash DD slash YYYY
Date Ended
*
MM slash DD slash YYYY
Position Held
*
Salary/Wage
*
Reason for Leaving
*
Were you subject to DOT rules while employed with this company?
*
Yes
No
While employed by this company, was your job designated as “safety-sensitive,” making you subject to the DOT drug and alcohol testing requirements?
*
Yes
No
Do you have additional employers to add?
*
Yes
No
Previous Employer
Company Name
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Person
*
Contact Phone Number
*
Date Started
*
MM slash DD slash YYYY
Date Ended
*
MM slash DD slash YYYY
Position Held
*
Salary/Wage
*
Reason for Leaving
*
Were you subject to DOT rules while employed with this company?
*
Yes
No
While employed by this company, was your job designated as “safety-sensitive,” making you subject to the DOT drug and alcohol testing requirements?
*
Yes
No
Do you have additional employers to add?
*
Yes
No
Previous Employer
Company Name
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Person
*
Contact Phone Number
*
Date Started
*
MM slash DD slash YYYY
Date Ended
*
MM slash DD slash YYYY
Position Held
*
Salary/Wage
*
Reason for Leaving
*
Were you subject to DOT rules while employed with this company?
*
Yes
No
While employed by this company, was your job designated as “safety-sensitive,” making you subject to the DOT drug and alcohol testing requirements?
*
Yes
No
Do you have additional employers to add?
*
Yes
No
Previous Employer
Company Name
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Person
*
Contact Phone Number
*
Date Started
*
MM slash DD slash YYYY
Date Ended
*
MM slash DD slash YYYY
Position Held
*
Salary/Wage
*
Reason for Leaving
*
Were you subject to DOT rules while employed with this company?
*
Yes
No
While employed by this company, was your job designated as “safety-sensitive,” making you subject to the DOT drug and alcohol testing requirements?
*
Yes
No
EXPERIENCE AND QUALIFICATIONS OF DRIVER APPLICANT
ACCIDENT RECORD FOR THE PAST 7 YEARS
Accidents to report:
None
Last Accident
Date
MM slash DD slash YYYY
Nature of the Accident
Fatalities:
No
Yes
Injuries:
No
Yes
Chargeable:
No
Yes
Can you provide documentation?
No
Yes
Previous Accident
Date
MM slash DD slash YYYY
Nature of the Accident
Fatalities:
No
Yes
Injuries:
No
Yes
Can you provide documentation?
No
Yes
Previous Accident
Date
MM slash DD slash YYYY
Nature of the Accident
Fatalities:
No
Yes
Injuries:
No
Yes
Can you provide documentation?
No
Yes
Previous Accident
Date
MM slash DD slash YYYY
Nature of the Accident
Fatalities:
No
Yes
Injuries:
No
Yes
Can you provide documentation?
No
Yes
TRAFFIC CONVICTIONS AND LICENSE FORFEITURES FOR THE LAST 7 YEARS, (OTHER THAN PARKING VIOLATIONS).
Traffic Convictions and License Forfeitures to report:
None
Most Recent Conviction or Forfeiture:
Location:
Date:
MM slash DD slash YYYY
Charge:
Penalty:
Most Recent Conviction or Forfeiture:
Location:
Date:
MM slash DD slash YYYY
Charge:
Penalty:
Most Recent Conviction or Forfeiture:
Location:
Date:
MM slash DD slash YYYY
Charge:
Penalty:
Most Recent Conviction or Forfeiture:
Location:
Date:
MM slash DD slash YYYY
Charge:
Penalty:
Driver's Licenses
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
License Number:
Type:
Expiration Date
Driver's Licenses
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
License Number:
Type:
Expiration Date
Driver's Licenses
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
License Number:
Type:
Expiration Date
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
*
No
Yes
Have you ever had any license, permit or privilege suspended or revoked?
*
No
Yes
IF THE ANSWER TO EITHER OF THE ABOVE TWO QUESTIONS IS “YES”, GIVE THE DETAILS.
DRIVING EXPERIENCE
Class of Equipment
Enter Amount of Experience for Each Type of Equipment
Straight Truck
CONTRACTOR’S DUMP
REGULAR DUMP TRUCK
TANKER
WRECKER
FLAT BED
VAN
REEFER
CEMENT TRUCK
BOOM TRUCK
SERVICE TRUCK
STRAIGHT TRUCK PULLING TRAILER
VAC TRUCK
Tractor Trailer
NON-HEATED, NON-REFRIGERATED, LIQUID TANKER
REFRIGERATED TANKER
DRY BULK TANKER
OPEN DUMP TRAILER
FLAT BED
REEFER
VAN
CAR CARRIER
DOUBLES
TRIPLES
Buses
STRAIGHT BUS (SCHOOL BUS, CHURCH BUS)
STRAIGHT COMMERCIAL BUS
DOUBLE
TRIPLE
Other
OTHER NOT LISTED
Flowerwood Management Inc
(d/b/a/ Flowerwood Trucking)
15315 Kelly Road
Loxley, AL 36551
TO BE READ AND SIGNED BY APPLICANT
This certifies that this application was completed by me, and that all entries on it and the information contained in this application, are true and complete to the best of my knowledge.
I authorize
Flowerwood Management Inc (d/b/a/ Flowerwood Trucking)
to make such investigations and inquiries of my personal, employment, driving, financial, medical, Drug and Alcohol Testing history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical, drug testing and alcohol testing history will be made only if and after a conditional offer of employment has been extended.). I hereby release former 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 further understand that any false or misleading information given in either my application or in interview(s) may result in discharge. I understand, also, that I will be required by
Flowerwood Management Inc (d/b/a/ Flowerwood Trucking)
to abide by all the rules and regulations of the company and any Federal/state agency. This includes all mandatory safety meetings/training meetings.
Signature
*
Date
*
MM slash DD slash YYYY
Flowerwood Management Inc (d/b/a/ Flowerwood Trucking)
Driver Safety Performance History
Records/Information Request Authorization
(Page 1 0f 3)
The Federal Motor Carrier Safety Administration rules outlined in 49 CFR Part 391.23 require that information regarding my Safety Performance History be provided to prospective employers for the preceding three (3) years. This record is my official request for the documentation to be released on behalf of my prospective employer:
TO:
Previous Employer
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Phone
Contact Fax
FROM:
Applicant Name
First
Last
Social Security Number
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Phone
I request this information be requested in the manner identified below: (check one)
*
Send the Information to the address below within five (5) business days via MAIL
I, the driver applicant, will arrange to PICK UP the information within 30 days
Please FAX the information to the number provided below within five (5) business days
Information should be sent to the following:
Transportation Safety Services
27540 World Court, Suite A
Daphne, AL 36526
Phone: (251) 661-9700
Fax: (251) 661-9667
Signature
*
Date
*
MM slash DD slash YYYY
Flowerwood Management Inc
(d/b/a/ Flowerwood Trucking)
Driver Safety Performance History
Applicant Rights
The Federal Motor Carrier Safety Administration promulgated rules to change the driver background check verifications required in 49 CFR Part 391 effective October 30, 2004. Under the new requirements
Flowerwood Management Inc (d/b/a/ Flowerwood Trucking)
is required to contact your previous employers for three (3) years previous to the date of your application for employment to verify certain specific safety information and records.
The information we will be requesting will include personal work history, accident involvement history, and the drug and alcohol testing history that they have on record. We will be reviewing information related to the time you were employed with each previous employer, and any information compiled by them as they performed Driver Safety Performance History checks as well.
As an applicant for a driving position, you have certain specific rights relating to the information that
Flowerwood Management Inc (d/b/a/ Flowerwood Trucking)
receives from your previous employer. These rights include:
1. The right to review the information provided to
Flowerwood Management Inc (d/b/a/ Flowerwood Trucking)
by your previous employers, whether you listed the employers specifically on your application for employment or not.
2. The right to have any errors in the information provided to
Flowerwood Management Inc (d/b/a/ Flowerwood Trucking)
corrected by a previous employer and to request that they submit corrected information.
3. The right to have a rebuttal statement attached to alleged erroneous information in such instance that you are not in agreement with the information provided to
Flowerwood Management Inc (d/b/a/ Flowerwood Trucking)
by a previous employer.
4. The right to review the information within provided to
Flowerwood Management Inc (d/b/a/ Flowerwood Trucking)
within 30 days of employment (or within 30 days from the date that employment is denied based on information received)
Flowerwood Management Inc (d/b/a/Flowerwood Trucking)
will provide such information to you upon receipt of your written request within five (5) business days.
I certify that I am a driver applicant and that I have read and understand my rights as prescribed by 49 CFR Part 391.
Signature
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Date
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Employee MVR Request Consent
Employee Name
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Address
Street Address
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State / Province / Region
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Driver's License Number
Driver's License State
Signature
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CERTIFICATION OF COMPLIANCE
WITH DRIVER LICENSE REQUIREMENTS
MOTOR CARRIER INSTRUCTIONS: The requirement in Part 383 applies to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placards.
The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placards.
Driver Requirements: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:
1. POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator’s license.
If you have more that one license, keep the license from your state or residence and return the additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If multiple licenses have been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state.
2. NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 392.42 and 383.33, of the Federal Motor Carrier Safety Regulations require that you notify your EMPLOYER the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: (1) your employing motor carrier, and (2) the state that issued your license (if the violation occurs in other that the one which issued your license). The notification to both the employer and state must be in writing.
The following license is the only one I will possess:
Driver's License Number
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State
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Expiration Date:
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DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.
Signature
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Date
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PRECEDING 7 DAYS DRIVER DUTY STATUS
INSTRUCTIONS: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8 (J) (2) Federal Motor Carrier Safety Regulations, NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form.
Driver Name
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First
Last
Social Security Number
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Driver's License State
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Driver's License Number
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Driver's License Class
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Driver's License Endorsement(s)
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Type of Driver's License
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Restriction(s)
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Day 1 (Yesterday)
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Hours Worked:
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Day 2
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MM slash DD slash YYYY
Hours Worked:
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Day 3
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MM slash DD slash YYYY
Hours Worked:
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Day 4
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MM slash DD slash YYYY
Hours Worked:
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Day 5
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Hours Worked:
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Day 6
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MM slash DD slash YYYY
Hours Worked:
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Day 7
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Hours Worked:
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I hereby certify that the information given above is correct to the best of my knowledge and belief.
Signature
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Date
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DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK
INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, also performing any compensated work for any non-motor carrier entity.
Are you currently working for another employer?
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No
Yes
At this time do you intend to work for another employer while still employed by this company?
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No
Yes
I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity.
Signature
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Date
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EMPLOYEE ALCOHOL AND DRUG STATEMENT
Section 40.25(j) As the employer, you must also ask the employee 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 testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (See Section 40.25(b) (5) and (e))
Flowerwood Management Inc
(d/b/a/ Flowerwood Trucking)
15315 Kelly Road
Loxley, AL 36551
Employee Name
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First
Last
Social Security Number
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The employee is required by Section 40.25 to respond to the following question:
1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules in the past three years?
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Yes
No
Signature
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Date
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Drug and Alcohol Testing Policy
Flowerwood Management Inc (d/b/a/ Flowerwood Trucking)
15315 Kelly Road
Loxley, AL 36551
This is the company’s official statement of drug and alcohol policy for its driving employees. Knowing how the use of these substances can affect the ability to operate a motor vehicle safely, we are implementing this policy to ensure that we are in compliance with the drug and alcohol testing requirements enacted by the DOT and listed in 49 CFR Parts 382 and 40. We are committed to provide a safe environment for each of our drivers and the motoring public.
To outline the DOT mandated situations under which you are required to be tested, we have listed the type of drug and alcohol tests that will be required of our drivers. These tests will be administered when the driver is performing a safety-sensitive function, generally defined as all time required to be logged as “on duty or driving” time on a driver daily log. The tests will either be administered while such duties are being performed, just before they are to be performed, or just after these duties have been completed. “Just before” or “just after” is defined as no longer than one hour. The tests will be administered and processed in accordance with the requirements of 49 CFR Part 40.
PRE-EMPLOYMENT (Drug only) – All drivers will be expected to submit to a pre-hire/pre-use drug test, the results of which must be obtained before the driver can be utilized the first time. Drivers failing this type of drug test are not qualified to be hired by the company.
RANDOM (Drug and Alcohol) – Drivers will continually be subject to DOT random testing after hire and throughout employment with the company. Testing administered will be spread throughout the year and unannounced, selected by a scientifically valid method from a pool of all employed drivers. The company (or its designee) will administer enough tests to the driver pool to ensure compliance with the minimum DOT requirements.
POST-ACCIDENT (Drug and Alcohol) – After drivers are involved in an accident, the company reserves the right to administer a drug test to each involved employee, without regard to fault, within 32 hours of the time the crash occurred. An alcohol test will also be obtained within eight hours of an accident, preferably in the first two hours.
REASONABLE SUSPICION (Drug and Alcohol) – At any time the company management notices indications of the use of drugs or abuse of alcohol by one of its drivers, which are contemporaneous and able to be articulated, the employee will be required to submit for testing.
All drivers who are required to possess a Commercial Driver’s License, or CDL, under the requirement of 49 CFR Part 383, are required to be tested for the presence of drug and alcohol. Upon notification of a required test, the driver
shall proceed immediately to the testing facility.
Failure to do so will be considered a refusal to submit to testing, which DOT treats the same as a POSITIVE test result.
There are significant consequences for submitting a test reported back as “POSITIVE” for drugs or alcohol, or refusing to be tested when required. Consequences for this type result are termination of employment, referral to a substance use evaluation facility, and release of the testing information to subsequent employers requesting such. Though DOT does not require termination of employment violations of Part 382, most employers choose to sever ties with the violating employee. DOT does require that employees be evaluated and receive treatment (as suggested by a substance professional) for substance problems. We are also required to release this information to your subsequent employers that request it of us.
Record keeping for drug and alcohol testing issues is typically maintained for a period of five (5) years, as required by the USDOT. If we are requested by another employer, to provide drug or alcohol testing information for a current or former employee of the company, records for the two (2) years previous to application for employment with the other employer will be provided, upon presentation of driver release for such information. This is in compliance with the requirements of 49 CFR parts 382.
The use of drugs and alcohol can have a significant impact on your health as our employee and on the safety of the motoring public. As a responsible member of the public using our nation’s highways, we will implement this policy as we strive to maximize the safety of our highways. If any questions regarding this policy arise, please do not hesitate to contact me for clarification.
I have reviewed this copy and understand its consequences. My signature below also represents that I have been notified that the type of tests, listed above, will periodically be required of me.
Signature
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Date
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