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1 About
2 Employment History
3 Testing
4 Pre-Employment Tests
5 Background
Viking Land Transportation

The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and of Viking Land Transportation.

Instructions to Applicant

Today's Date

Please answer all questions. If the answer to any question is "No" or "None", do not leave the item blank, but write "No" or "None".

Nameyour full name
DOBmm/dd/yyyy
*AgeYour Age
Address
City
Zip
Drivers License #
Expire Date
DOT Phy. Ex. Exp. Date
Home Phone
Cell Phone
Emergency Phone Number

3 Years Previous Address:

Address
From
To
Address
From
To
Address
From
To
Position Applying For:

*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

Have You Worked for this Company Before?

I Worked Here

From
Until
Reason For Leaving
EMPLOYMENT HISTORY

Give a COMPLETE RECORD of ALL employment for the past 10 year, including any unemployment or self employment and all commercial driving experience for the past ten years. 

Current or Past Employer
Address
From
To
Position Held
Salary
Phone Number
Reason For Leaving
Were You Subject to the FMCSR* while Employed Here?
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 40?
Next Past Employer
Past Employer
Address
From
To
Position Held
Salary
Phone Number
Reason For Leaving
Were You Subject to the FMCSR* while Employed Here?
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 40?
Next Past Employer
Past Employer
Address
From
To
Position Held
Salary
Phone Number
Reason For Leaving
Were You Subject to the FMCSR* while Employed Here?
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 40?
Next Past Employer
Past Employer
Address
From
To
Position Held
Salary
Phone Number
Reason For Leaving
Were You Subject to the FMCSR* while Employed Here?
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 40?
Next Past Employer
Past Employer
Address
From
To
Position Held
Salary
Phone Number
Reason For Leaving
Were You Subject to the FMCSR* while Employed Here?
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 40?
Controlled Substance & Alcohol Testing Information Acknowledgement/Consent Form

As a condition of employment with  Viking Land (Motor Carrier), Commercial Motor Vehicle (CMV) Driver Applicants must submit to a pre-employment controlled substances test as required by the Federal Motor Carrier Safety Regulations (FMCSR) Section 3B2.301. A motor carrier must receive verified negative test results for the applicant driver for the applicant to be eligible for employment.

If you are hired, you will be subject to laws requiring additional controlled substances and alcohol testing on you under numerous situations including, but not limited to, the following:

Post-Accident - Section 382.303

Random - Section 382.305

Reasonable Suspicion - Section 382.307

Return to Duty - Section 382.309

Follow-up Section 382.311

All controlled substances and alcohol testing will be conducted in accordance with Parts 40 and 382 of the FMCSR.

A driver who tests positive for a controlled substance(s)and/or alcohol test, will be immediately removed from a safety sensitive position as required by Part 382 of the FMCSR. Federal law prohibits a driver from returning to a safety sensitive position for any motor carrier until and unless the driver completes the Substance Abuse Professionals (SAP) evaluation,referral and educational/treatment process, as described in FMCSR Part 40,Subpart 0.

I have read the above controlled substances and alcohol testing requirements and understand them.
To be Read by the Applicant

TO BE READ AND SIGNED BY THE APPLICANT

It is agreed and understood that any misrepresentation given above shall be considered an act of dishonesty.

It is further agreed and understood that Viking Land may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant release employers and persons named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91 - 508,1 have been told that this investigation may include an Investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

It is agreed and understood that this application for qualification in no way obligates Viking Land to employ the applicant.

It is agreed and understood that if qualified, the driver may be on a probationary period during which time he may be disqualified without recourse.

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.

I Understand
PERSONAL REFERENCES

List three Persons for reference, other than relatives, who have knowledge of your safety habits.

Name
Address
Phone Number
Name
Address
Phone Number
Name
Address
Phone Number
DRIVING EXPERIENCE

Straight Truck

To
From
# of Miles

Tractor/Semi Trailer

To
From
# of Miles

Tractor - Two Trailers

To
From
# of Miles

Other

To
From
# of Miles
List States Operated in for the last 5 Years:
0 /
Show Special Courses or Training that will help you as a Driver:
0 /
What Safe Driving Awards do you hold and from whom?
0 /
ACCIDENT RECORD FOR PAST 3 YEARS
Date
Nature of Accident
Fatalities
Injured
Date
Nature of Accident
Fatalities
Injured
Date
Nature of Accident
Fatalities
Injured
Date
Nature of Accident
Fatalities
Injured
TRAFFIC CONVICTIONS & FORFEITURES FOR THE LAST 3 YEARS

(Other than parking violations)

Location
Date
Charge
Penalty
Location
Date
Charge
Penalty
Location
Date
Charge
Penalty
DRIVER'S LICENSE (list each driver's license held in the past 10 years)
State
License #
Type
Endorsements
Ex.
State
License #
Type
Endorsements
Ex.
State
License #
Type
Endorsements
Ex.
Have you even been denied a license, permit or privilege to operate a motor vehicle?
A.) Has any license, permit or privilege ever been suspended or revoked?
B.) Has any license, permit or privilege ever been suspended or revoked?
C.) Is there any reason you might be unable to perform the functions of the job for which you have applied (as descripbed in the job description)
D.) Have you ever been convicted of a felony?
If the answer to A or B is YES, give details
0 /
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