Fill out our easy employment application today

Name*

First

Middle

Last
Address*

Street Address

Address Line 2

City

State

ZIP Code
Email*
Cell Phone*
Home Phone
Business Phone
Position Desired*
Pay Expected
Have you applied here previously?*
- Yes
- No
Previous application date (mm/yyyy)
Have you worked for this company before?*
- Yes
- No
If yes, where?
Previous employment start date (mm/yyyy)
Previous employment end date (mm/yyyy)
Previous position
Previous rate of pay
Are you legally eligible to work in the United States*
- Yes
- No
Available Start Date*

Date Format: MM slash DD slash YYYY
Are you currently employed?*
- Yes
- No
When did you leave your last employment?

Date Format: MM slash DD slash YYYY
How were you referred to this company?
Referral Name

Education*

Name and School Location Course of Study Years Completed Graduated? Degree or Diploma
Membership in Professional or Civic Organizations

(Exclude those which may disclose your race, color, religion, or national origin)

Employment – Last 10 Years*

Company Name Telephone Address Started (Month/Year) Ended (Month/Year) Address Supervisor Your Title and Job Duties Reason for Leaving

Please give an accurate and complete record of your full and part-time employment. Start with your present or most
recent employer.
Have you ever been discharged from a job?*
- Yes
- No
What were the circumstances of your discharge?

Include employer name, date of discharge, and reason.

Social Security No.*
Commercial Driver License Number*
Expiration Date*

Date Format: MM slash DD slash YYYY
Issuing State*
Date of Birth*

Date Format: MM slash DD slash YYYY
Endorsements
Have you held a driver's license in any other state in the last 5 years?*
- Yes
- No
Which states?
Driving Experience*

Equipment Type Years City Miles (approx.) Highway Miles (approx.)

(Straight, Tractor/Trailer, Van, or Other)
Specialized Training
If you attended a CDL School, list when and where:
Please list any special courses for training that will help your employment as a driver (i.e. defensive driving, skid pad, etc.)

Course Date Location
Have you ever received safe driving awards? If yes, when and from whom?

Accident Record – Past 10 Years

Date Type Vehicle Injuries Location Disposition
Violation Record – Past 10 Years

Date Type Vehicle Injuries Location Disposition
Has your license ever been suspended or revoked?*
- Yes
- No
Date of suspension or revoke:
Have you ever been convicted of reckless driving, careless driving or careless operation of a motor vehicle?*
- Yes
- No
Conviction date:
Have you ever been convicted of driving under the influence of alcohol, narcotics, drugs, marijuana, amphetamines, or any illegal substance?*
- Yes
- No
Conviction date:

Did you serve in the US Armed Services?*
- Yes
- No
What branch?
Describe any training you received in the military that is relevant to the work for which you are applying.
Have you ever been convicted of a felonious crime?*
- Yes
- No
Date of Conviction?

Date Format: MM slash DD slash YYYY
What was the crime?
Work References*

Person Title Business Contact Information

Please list 3.
Personal References*

Person Relationship Contact Information

Please list 3.

EMPLOYMENT RELATIONSHIP
1. I agree that any misleading or untrue statement, answer or omission herein or hereafter, at the sole option of the company, may render
  void this application for employment and may result in termination should employment have been offered or granted.
2. I understand and agree that this application for employment may be used for background and security investigation. I authorize the
  company to inquire into my application and background. I authorize the company to contact former employers, educators,
  references and other persons and organizations for any and all information regarding my qualifications for employment.
3. In the event the company offers employment to me, I understand and agree that such an offer is conditional on my demonstrating
  through a company-paid physical examination the ability to perform essential functions of the offered position with or without
  reasonable accommodation. I authorize the company to inquire into my medical background as it affects my qualifications for
  employment and eligibility for health plans and insurance. I request and authorize all doctors, treatment providers, hospitals or medical
  facilities to release and furnish such information regarding my medical history and records and, in consideration for doing so, I
  especially discharge, relieve and release any persons and facilities furnishing such information from any liability.
4. I understand and agree that my employment with the company, including employment in subsequent positions or status, may be
  terminated by me or by the company at any time, for any reason, with or without cause and with or without notice. This agreement can
  be modified only by specific agreement in writing, signed by both parties, and cannot be modified by subsequent conduct of the parties.
  I understand that no manager or agent of the company other than the CEO has any authority to enter into any agreement for employment
  for any specific period of time or to make any agreement contrary to the foregoing.
5. In the event I accept employment with the company, I agree and promise to ascertain and abide by all pertinent company rules, policies
  and procedures, and I agree that failure to do so may result in termination of such employment. I understand that these rules, policies, and procedures may be amended at any time the company deems appropriate. I understand that this does not alter my right nor the
  company’s right to terminate my employment at any time, for any reason, with or without notice.
6. I hereby authorize the company to deduct from each and every pay period any amounts necessary to offset any damages caused by
  me or the value of property or money entrusted to me by, or owed by me to, the company during the course of my employment.
7. I acknowledge that any claim that “may arise out of my employment or termination of employment must be brought within 180 days of the
  event giving rise to the claims or be forever barred.”
8. I acknowledge the employer’s right to recoup attorney fees if the employer prevails in the defense of any employment claims initiated by me.
Signature*
Date*

Date Format: MM slash DD slash YYYY

Certification of a Positive Pre-Employment Drug or Alcohol

Test Result or Report of Refusal to Test
In compliance with the provisions of the Federal Motor Carrier Safety Regulations regarding the
Procedures of Transportation Workplace Drug and Alcohol Testing Programs (49 CFR Part
40.25 j), every person applying for a safety-sensitive position with a Commercial Motor Carrier
must answer the following:
1. In the past two years have you ever tested positive on any pre-employment drug or
alcohol test administered by an employer to which you applied for, but did not obtain,
safety-sensitive work in areas covered by DOT agency Drug and Alcohol Testing rules?
Drug?*
- Yes
- No
Alcohol?*
- Yes
- No
2. In the past two years have you ever refused any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safetysensitive transportation work covered by DOT agency Drug and Alcohol testing rules?*
- Yes
- No
3. In the past have you ever refused or tested positive for any random drug or alcohol tests administered by your employer?*
- Yes
- No
If any of the above were answered YES, please complete the following:
Company name and address for which you applied for, but did not obtain, safety-sensitive
transportation work:
Company Name
Address

Street Address

City

State

ZIP Code
Name of Contact
Date of Positive Test or Test Refusal:

Date Format: MM slash DD slash YYYY
Name, address, and telephone number of the Substance Abuse Professional (SAP) that
approved your return to duty:
(SAP) Name
(SAP) Address

Street Address

City

State

ZIP Code
(SAP) Phone Number
(SAP)
- I did not see a Substance Abuse Professional following this event.
I certify, by my signature, that the information above is true and correct. I understand
that providing false or misleading information is a serious violation of federal law and, if
approved for a driving position, doing so could be cause for the immediate termination of
any employment or contractual agreement I may have with the company.
Signature*
Date

Date Format: MM slash DD slash YYYY
SSN*

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY
ALL ACCOUNT HOLDERS

MPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Holland Special Delivery (“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 Prospective 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 did 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 FM CSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective 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 Holland Special Delivery (“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 five (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 l challenge crash or inspection information reported by a State, FMCSA
cannot change or correct this data. I understand my request will be forwarded by 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 all 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 adjudicated 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 l sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to
obtain the information authorized above.
Signature*
Date

Date Format: MM slash DD slash YYYY
Name*
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety
Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP
report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The
language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included
with other consent forms or any other language.
LAST UPDATED 12/22/2015

Employment Application

Step 1 of 9

EMPLOYMENT RELATIONSHIP

Certification of a Positive Pre-Employment Drug or Alcohol

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY
ALL ACCOUNT HOLDERS

MPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

AUTHORIZATION

Holland Special Delivery

Name and School Location	Course of Study	Years Completed	Graduated?	Degree or Diploma

Company Name	Telephone	Address	Started (Month/Year)	Ended (Month/Year)	Address	Supervisor	Your Title and Job Duties	Reason for Leaving

Equipment Type	Years	City Miles (approx.)	Highway Miles (approx.)

Date	Type	Vehicle	Injuries	Location	Disposition

Date	Type	Vehicle	Injuries	Location	Disposition

Person	Title	Business	Contact Information

Person	Relationship	Contact Information

Employment Application

Step 1 of 9

EMPLOYMENT RELATIONSHIP

Certification of a Positive Pre-Employment Drug or Alcohol

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

MPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

AUTHORIZATION

Holland Special Delivery

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY
ALL ACCOUNT HOLDERS

MPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service