BTA, Inc.

Contact Information

Name

Street

City

State

Zip Code

Email Address

Previous Addresses

Street	City	State	Zip	How long?

Add a Previous Address

Do you have the legal right to work in the United States?

Date of birth:

Can you provide proof of your age?

Have you worked at BTA, Inc. before?

If you've worked for BTA, Inc. before...

Where did you work?

Start Date

End Date

Reason for leaving:

Are you now employed?

If not, how long since leaving last employment?

Have you ever been bonded?

If yes, name of bonding company:

Have you ever been convicted of a felony? Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.

Please fully explain your felony conviction.

Is there any reason you might be unable to perform the functions of the job for which you have applied as described in the job description? Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.

Please explain if you wish.

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial vehicle† in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle.

(NOTE: List employers in reverse order starting with the most recent.)

Employer Name

Address

City

State

Zip Code

Contact Person

Phone Number

From

To

Position held:

Salary/Wage:

Reason for leaving:

Were you subject to the FMCSRs‡ while employed?

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Add an Employer

† Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

‡ The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weight or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Accident Record

Have you had any accidents in the past 3 years?

List all accidents for the past 3 or more years.

Date	Nature of Accident (head-on, rear-end, upset, etc.)	Fatalities	Injuries	Hazardous Material Spill

Add an Accident

Traffic Convictions

Have you had any traffic convictions in the past 3 years?

List all traffic convictions for the past 3 or more years.

Date	Location	Charge	Penalty

Add a Traffic Conviction

Driver's Licenses

List all driver licenses or permits held in the past 3 years.

State	License No.	Type	Expiration Date

Add a Driver's License

Experience and Qualifications

Show any trucking, transportation, or other experience that may help in your work for this company:

List courses and training other than shown elsewhere in this application:

List special equipment or technical materials you can work with (other than those already shown):

Driving Experience

Equipment

Class of Equipment	Type of Equipment	Dates		Approx. Total Miles
Class of Equipment	Type of Equipment	From	To	Approx. Total Miles
Straight Truck
Tractor and Semi-Trailer
Tractor and Two Trailers
Tractor and Three Trailers
Motorcoach - School Bus More than 16 passengers.
Motorcoach - School Bus More than 8 passengers.
Other

States

Select states you've operated in over the last five years:

Add a State

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

Which safe driving awards do you hold and from whom?

Education

Select the highest grade completed:

Last School Attended

Name

City, State

Agreement

I authorize you to make such investigations and inquiries of 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 require by 49 CFR 391.23(d) and (e). I understand that I have the right to:

Review information provided by previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send 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.

I agree.

Signature Type your name to sign.

Date

Application: Driver