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Application For Employment

Pre-employment questionnaire. Equal opportunity employer.

Step 1 of 10

LICENSE INFORMATION - if applying for a driving position
STATE
LICENSE NO.
TYPE
EXPIRATION DATE:
MM slash DD slash YYYY
DRIVING EXPERIENCE- if applying for a driving position
DRIVING EXPERIENCE #1
CLASS OF EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.) DATE FROM DATE TO APPROX. # OF MILES
DRIVING EXPERIENCE #2
CLASS OF EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.) DATE FROM DATE TO APPROX. # OF MILES
DRIVING EXPERIENCE #3
CLASS OF EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.) DATE FROM DATE TO APPROX. # OF MILES
DRIVING EXPERIENCE #4
CLASS OF EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.) DATE FROM DATE TO APPROX. # OF MILES
DRIVING EXPERIENCE #5
CLASS OF EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.) DATE FROM DATE TO APPROX. # OF MILES
ACCIDENT RECORD FOR PAST THREE (3) YEARS OR MORE - if applying for a driving position (ATTACH SHEET IF MORE ROOM IS NEEDED)
ACCIDENT RECORD #1
DATE NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.) NUMBER OF FATALITIES NUMBER OF INJURIES CHEMICAL SPILL (YES OR NO)
ACCIDENT RECORD #2
DATE NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.) NUMBER OF FATALITIES NUMBER OF INJURIES CHEMICAL SPILL (YES OR NO)
ACCIDENT RECORD #3
DATE NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.) NUMBER OF FATALITIES NUMBER OF INJURIES CHEMICAL SPILL (YES OR NO)
ACCIDENT RECORD #4
DATE NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.) NUMBER OF FATALITIES NUMBER OF INJURIES CHEMICAL SPILL (YES OR NO)
TRAFFIC CONVICTIONS AND FOREFEITURES FOR PAST THREE (3) YEARS-if applying for a driving position (OTHER THAN PARKING VIOLATIONS)
TRAFFIC CONVICTIONS AND FOREFEITURES #1
DATE VIOLATION STATE OF VIOLATION LOCATION PENALTY (FORFEITED BOND, COLLATERAL AND/OR POINTS)
TRAFFIC CONVICTIONS AND FOREFEITURES #2
DATE VIOLATION STATE OF VIOLATION LOCATION PENALTY (FORFEITED BOND, COLLATERAL AND/OR POINTS)
TRAFFIC CONVICTIONS AND FOREFEITURES #3
DATE VIOLATION STATE OF VIOLATION LOCATION PENALTY (FORFEITED BOND, COLLATERAL AND/OR POINTS)
TRAFFIC CONVICTIONS AND FOREFEITURES #4
DATE VIOLATION STATE OF VIOLATION LOCATION PENALTY (FORFEITED BOND, COLLATERAL AND/OR POINTS)
TRAFFIC CONVICTIONS AND FOREFEITURES #5
DATE VIOLATION STATE OF VIOLATION LOCATION PENALTY (FORFEITED BOND, COLLATERAL AND/OR POINTS)
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
If yes, explain
Has any licesne, permit or privilege ever been suspended or revoked?
If yes, explain

EMPLOYMENT RECORD
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the intial three years (total of ten years employment record). Use an additonal sheet if necessary. Must list the complete mailing address: street number and name, city, state, and zip code
NAME OF LAST EMPLOYER:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date Start
MM slash DD slash YYYY
Date End
MM slash DD slash YYYY
POSITION HELD:
SUPERVISOR'S NAME:
EMPLOYER'S OR SUPERVISOR'S PHONE #:
REASONS FOR LEAVING:
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON:
Were you subject to the Federal Motor Carrier safety Regulations (FMCSRs) while employed by the previous employer?
Was the previous job position designed as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirments as required by 49 CFR Part 40?
EMPLOYMENT RECORD CONTINUED
SECOND LAST EMPLOYER:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date Start
MM slash DD slash YYYY
Date End
MM slash DD slash YYYY
POSITION HELD:
SUPERVISOR'S NAME:
EMPLOYER'S OR SUPERVISOR'S PHONE #:
REASONS FOR LEAVING:
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON:
Were you subject to the Federal Motor Carrier safety Regulations (FMCSRs) while employed by the previous employer?
Was the previous job position designed as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirments as required by 49 CFR Part 40?
EMPLOYMENT RECORD CONTINUED
THIRD LAST EMPLOYER:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date Start
MM slash DD slash YYYY
Date End
MM slash DD slash YYYY
POSITION HELD:
SUPERVISOR'S NAME:
EMPLOYER'S OR SUPERVISOR'S PHONE #:
REASONS FOR LEAVING:
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON:
Were you subject to the Federal Motor Carrier safety Regulations (FMCSRs) while employed by the previous employer?
Was the previous job position designed as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirments as required by 49 CFR Part 40?

TO BE READ AND SIGNED BY APPLICANT
I authorize you to make sure investigations and inquiries to 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 the Company. "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 49 CFR 391.23(d) and €. I understand that I have the right to: - Review information provided by current/previous employers; - Have errors in the informaiton corrected by previous employers and for those previous employers to re-send the corrected informaiton 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."
Date
MM slash DD slash YYYY
Signature

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 carrieA95:F102r may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations

GENERAL CONSENT FOR MOTOR VEHICLE RECORD (MVR)
In conjunction with my employment at EarthX (“the company”), I

(employee/applicant name) Consent to the release of (print name) my Motor Vehicle Record (MVR) to the company. I understand the company will use these records to evaluate my suitability to fulfill driving duties that may be related to the position for which I am applying. I also consent to the review, evaluation, and other use of any MVR I may have provided to the company. This consent is given in satisfaction of Public Law 18 USC 2721 et. Seq.. “Federal Drivers Privacy Protection Act”, and is intended to constitute “written consent” as required by this Act.
Signature
Date
MM slash DD slash YYYY
Date of Birth
MM slash DD slash YYYY
SSN# (Last 4 digits)
Driver's License Number
Driver's License Number License Expiration Date
MM slash DD slash YYYY

ALL DRIVER SELF-VERIFICATION FORM
Name
First Last
Date of Application
MM slash DD slash YYYY
Position Applied For
Position Desired
Date of Interview
MM slash DD slash YYYY
Date of Hire
MM slash DD slash YYYY
I verify that the following information is true and correct:
I am at least 21 years of age.
I read and speak English well enough to converse with the general public and respond to official inquiries, etc.
By reason of experience, training, or both, I can safely operate the type of vehicle I will be driving.
I have been deemed physically qualified to drive a commercial motor nehcile in accordance with FMCSRs Subpart E - Physical Qualifications and Exams, as evidenced by a Medical Card signed by an approved provider.
My CMV operator's license is currently valid.
I have provided EarthX with a list of all of my violations.
I am not disqualified to drive a CMV under the rules.
I have successfully completed a road test or provided a copy of my current and valid CDL.
Signature:
Printed Name:
Date
MM slash DD slash YYYY

DRUG FREE WORK PLACE POLICY EMPLOYEE RECEIPT FORM
Prepared for: EarthX Prepared by: Front Range Compliance Services, LLC March 30th, 2023 Policy & Procedure: 3228018-03302023-ver.2 I hereby acknowledge that I have received a copy of Earthx Drug Free Work Place Policy. I also acknowledge that I have received a full and complete explanation of the program, including all policies and the availability of an employee assistance program. I have had the terms and conditions of the Earthx Alcohol and Controlled Substances Testing Policy explained to me, and I freely and voluntarily consent to submit to drug and alcohol screening or testing as set forth in Earthx Policy. I understand that violation of a provision of this policy will lead to disciplinary action up to and including termination of employment, and that I may forfeit my unemployment and workers’ compensation benefits. I further agree to and hereby authorize the release of the results of said tests to the Earthx Medical Review Officer (MRO) and as set forth in the company drug and alcohol testing policy. Finally, I agree that neither the issuance of these policies, nor the acknowledgment of its receipt, constitutes or implies a contract of employment or a guaranteed right to recall.
Employee Name (printed)
Employee Signature
Date
MM slash DD slash YYYY

FMCSA ALCOHOL AND CONTROLLED SUBSTANCES TESTING PROGRAM & POLICY RECEIPT FORM
Prepared by: Front Range Compliance Services, LLC March 30th, 2023 Policy & Procedure: 3228018-03302023-ver.2 I hereby acknowledge that I have received a copy of Earthx Alcohol and Controlled Substances testing policy. I also acknowledge that I have received a full and complete explanation of the program, including all policies and the availability of an employee assistance program. I have had the terms and conditions of the Earthx Alcohol and Controlled Substances Testing Policy explained to me, and I freely and voluntarily consent to submit to drug and alcohol screening or testing as set forth in Earthx Policy. I understand that violation of a provision of this policy may lead to disciplinary action up to and including termination of employment, and that I may forfeit my unemployment and workers’ compensation benefits. I understand Earthx has developed a policy in conformity with DOT Regulations 49 CFR Parts 40 & 382 regarding the illegal use of drugs and the abuse of alcohol. A copy of these Federal Regulations is on file with Earthx Designated Employer Representative (DER) for review at any time during normal working hours. I further agree to and hereby authorize the release of the results of said tests to the Earthx Medical Review Officer (MRO) and as set forth in the company drug and alcohol testing policy. Finally, I agree that neither the issuance of these policies, nor the acknowledgment of its receipt, constitutes or implies a contract of employment or a guaranteed right to recall
Employee Name (printed)
Employee Signature
Date
MM slash DD slash YYYY

GENERAL CONSENT FOR LIMITED QUERIES OF THE FMCSA DRUG AND ALCOHOL CLEARINGHOUSE
I

hereby provide consent to Earthx to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse at any point during my employment with Earthx. I understand that if the limited query conducted by Earthx indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Earthx without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for Earthx to conduct a limited query of the Clearinghouse, Earthx must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.
Employee Signature
Date
MM slash DD slash YYYY

MVRcheck.com PSP BACKGROUND REPORT RELEASE IMPORTANT DISCLOSURE
In connection with your application for employment with _______________________ (”Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospection Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA: the name, address, and the toll free telephone number of FMCSA: that the FMCSA didn’t not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken: and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospection Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication. Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault, Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. The Prospective Employer cannot obtain background reports from FMCSA without your authorization AUTHORIZATION If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize ______________________ (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous 5 (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a Stat, FMCSA cannot change or correct this data. I understand my request will be forwarded but the DataQs system to the appropriate State for adjudication. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adducted by a court of law will also appear, and remain on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sing this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I nearby authorize Prospective Employer and its employees, authorized agents: and/or affiliates to obtain the information authorized above.
Name
First Last
Signiture
Date
MM slash DD slash YYYY

Careers

Application For Employment

Step 1 of 10

PERSONAL INFORMATION

PREVIOUS THREE YEARS RESIDENCY

LICENSE INFORMATION - if applying for a driving position

DRIVING EXPERIENCE- if applying for a driving position

ACCIDENT RECORD FOR PAST THREE (3) YEARS OR MORE - if applying for a driving position (ATTACH SHEET IF MORE ROOM IS NEEDED)

TRAFFIC CONVICTIONS AND FOREFEITURES FOR PAST THREE (3) YEARS-if applying for a driving position (OTHER THAN PARKING VIOLATIONS)

EMPLOYMENT RECORD

EMPLOYMENT RECORD CONTINUED

EMPLOYMENT RECORD CONTINUED

TO BE READ AND SIGNED BY APPLICANT

GENERAL CONSENT FOR MOTOR VEHICLE RECORD (MVR)

ALL DRIVER SELF-VERIFICATION FORM

DRUG FREE WORK PLACE POLICY EMPLOYEE RECEIPT FORM

FMCSA ALCOHOL AND CONTROLLED SUBSTANCES TESTING PROGRAM & POLICY RECEIPT FORM

GENERAL CONSENT FOR LIMITED QUERIES OF THE FMCSA DRUG AND ALCOHOL CLEARINGHOUSE

MVRcheck.com PSP BACKGROUND REPORT RELEASE IMPORTANT DISCLOSURE

Address

Phone

Email

CLASS OF EQUIPMENT	TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	DATE FROM	DATE TO	APPROX. # OF MILES

CLASS OF EQUIPMENT	TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	DATE FROM	DATE TO	APPROX. # OF MILES

CLASS OF EQUIPMENT	TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	DATE FROM	DATE TO	APPROX. # OF MILES

CLASS OF EQUIPMENT	TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	DATE FROM	DATE TO	APPROX. # OF MILES