Application

    Haul It All, LLC

    ADDRESSES FOR THE LAST 10 YEARS:

    (If additional space is needed, please attach a separate page)

    DO YOU HAVE A TRANSPORTATION WORKER IDENTIFICATION CREDENTIAL (TWIC) CARD?

    HAVE YOU EVER TAKEN A TRUCK DRIVING COURSE?

    YesNo

    DO YOU HAVE A FREE & SECURE TRADE (FAST) CARD FOR BORDER CROSSINGS?

    YesNo

    HAVE YOU EVER BEEN CONVICTED OF A CRIME OR ARE PRESENTLY INVOLVED IN CRIMINAL PROCEEDINGS?

    YesNo

    DRUG AND ALCOHOL TESTING

    DID A D.O.T. ALCOHOL TEST, CONDUCTED WITHIN THE LAST TWO YEARS, CONFIRM A B.A.C OF 0.04 OR GREATER?

    YesNo

    DID A D.O.T. CONTROLLED SUBSTANCE TEST WITHIN THE LAST TWO YEARS RESULT IN A CONFIRMED “POSITIVE” RESULT?

    YesNo

    HAVE YOU EVER REFUSED TO BE TESTED AS REQUIRED BY D.O.T. REGULATIONS?

    YesNo

    IF NO TO ALL OF THE ABOVE, GO TO DRIVING HISTORY ON NEXT PAGE

    TYPE OF TEST: ALCOHOL CONTROLLED SUBSTANCE BOTH

    DID YOU RETURN TO DUTY WITH YOUR COMPANY FOLLOWING EVALUATION BY A SUBSTANCE ABUSE PROFESSIONAL (SAP)?

    YesNo

    WAS FOLLOW-UP TESTING REQUIRED AND PERFORMED?

    YesNo

    DRIVING HISTORY LIST ANY LICENSE YOU HAVE HELD IN THE LAST 10 YEARS.

    Have any of these licenses been revoked, suspended, restricted or denied?

    YesNo

    ACCIDENTS- LIST ANY YOU HAVE BEEN INVOLVED IN FOR THE LAST 3 YEARS.

    MOVING VIOLATIONS- LIST ANY YOU HAVE HAD IN THE LAST 3 YEARS.

    EXPERIENCE:

    WORK HISTORY: Give a COMPLETE and consecutive history of your employment for the last 10 years, starting with the present or most recent employer. Please account for all months

    REMEMBER- AN INCOMPLETE DATA SHEET WILL PREVENT PROCESSING

    MOST RECENT EMPLOYER:

    Were you subject to FMCSRs while employed?

    YesNo

    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?

    YesNo

    Were you subject to FMCSRs while employed?

    YesNo

    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?

    YesNo

    Were you subject to FMCSRs while employed?

    YesNo

    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?

    YesNo

    Were you subject to FMCSRs while employed?

    YesNo

    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?

    YesNo

    Were you subject to FMCSRs while employed?

    YesNo

    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?

    YesNo

    Were you subject to FMCSRs while employed?

    YesNo

    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?

    YesNo

    Were you subject to FMCSRs while employed?

    YesNo

    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?

    YesNo

    Were you subject to FMCSRs while employed?

    YesNo

    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?

    YesNo

    Were you subject to FMCSRs while employed?

    YesNo

    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?

    YesNo

    Were you subject to FMCSRs while employed?

    YesNo

    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?

    YesNo

    Were you subject to FMCSRs while employed?

    YesNo

    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?

    YesNo