Flatbed Express Inc.

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Driver’s Application For Employment
All fields marked in bold are required.

In compliance with federal and state equal employment opportunity laws, qualified applicants
are considered for employment without regard to race, color, religion, sex, national origin, age, marital status, or non job-related medical conditions or handicaps.

Date:

How did you hear about us?

Name & Address
First Name:		Last Name:
Home Phone:		Cell/Pager:
Address:		City:
State:		Zip Code:

Addresses for the last 3 years
Address:		City:
State:		Zip Code:

Address:		City:
State:		Zip Code:

Personal Information
Social Security Number :		Date of Birth:

Have you ever worked for Flatbed Express before?	Yes	No
If yes, please give dates of employment	From:	To:
Reason for leaving:

Are you currently employed?

If not, how long since you were employed?

Driver's License(s)
Please list all driver's licenses you have held in the past 5 years (first line is required)
State	License Number	Type of License	Exp. Date

List all employment for the last 10 years, starting with present or most current employer
1. Company:	Address:
City:	State:
Zip Code:	Phone:
Dates Employed
From:	To:
Position:	Reason for leaving:
May we contact your present employer?	Yes	No
*Were you subject to the FMCSRs while employed?**	Yes	No
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?**	Yes	No

2. Company:	Address:
City:	State:
Zip Code:	Phone:
Dates Employed
From:	To:
Position:	Reason for leaving:
Were you subject to the FMCSRs* while employed?	Yes	No
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**?	Yes	No

3. Company:	Address:
City:	State:
Zip Code:	Phone:
Dates Employed
From:	To:
Position:	Reason for leaving:
Were you subject to the FMCSRs* while employed?	Yes	No
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**?	Yes	No

4. Company:	Address:
City:	State:
Zip Code:	Phone:
Dates Employed
From:	To:
Position:	Reason for leaving:
Were you subject to the FMCSRs* while employed?	Yes	No
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**?	Yes	No

5. Company:	Address:
City:	State:
Zip Code:	Phone:
Dates Employed
From:	To:
Position:	Reason for leaving:
Were you subject to the FMCSRs* while employed?	Yes	No
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**?	Yes	No

6. Company:	Address:
City:	State:
Zip Code:	Phone:
Dates Employed
From:	To:
Position:	Reason for leaving:
Were you subject to the FMCSRs* while employed?	Yes	No
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**?	Yes	No

7. Company:	Address:
City:	State:
Zip Code:	Phone:
Dates Employed
From:	To:
Position:	Reason for leaving:
Were you subject to the FMCSRs* while employed?	Yes	No
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**?	Yes	No

*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone driving a motor vehicle on the highway in interstate commerce to transport passengers or property when the vehicle (1) weighs or has a GVWR of 26,001 pounds or more, (2) is designed or used to transport 9 or more passengers including the driver, (3) is used to transport hazardous materials in a quantity requiring placarding.

**Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 15 or more passengers or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

A. Have you ever been denied a license, permit, or a privilege to operate a motor vehicle?	Yes	No
B. Has any license, permit, or privilege been suspended or revoked?	Yes	No
C. Have you ever been convicted for driving while intoxicated?	Yes	No
D. Have you ever been convicted for possession, sale, or use of a narcotic drug, amphetamine, or derivative thereof?	Yes	No
E. Have you ever been refused auto liability insurance?	Yes	No
If you answered yes to questions A, B, C, D, or E; please state the circumstances and dates they occurred.

Traffic convictions and forfeitures for the past 5 years (If none, type "none" in the each box of the first row, first row required)
Location	Date	Offense	Penalty

Accident record for the past 5 years (If none, type "none" in the each box of the first row, first row required)
Date	Type of Accident Head-on, Backing, etc.	Fatalities	Injuries

Driving Experience (Vans, Flatbed, Refrigerated, Straight, Etc., first row required)
Type of Equipment	Date To	Date From	Approx. Number of Miles/Hours

To Be Read And Signed By The Applicant

1. As part of the application process, it is understood that certain pre-qualification procedures are involved. I understand and agree that during this period, I am not an employee of Flatbed Express Inc., and am not entitled to receive any pay or other compensation for my time spent in these activities. No testing by the Company shall be deemed to be hiring and until such time as I receive notification from a Company official that I have been hired, my position is that of an applicant.

2. I understand that nothing contained in this employment application is intended to create an employment contract between this Company and myself for either employment or for providing of any benefit. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon this Company unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that this Company has the same right.

3. If I am hired, in consideration of my employment, I agree to conform to the rules, regulations, and standard operating procedures of the Company as they may now or hereafter exist and also agree that my employment and compensation can be changed or terminated, with or without cause, and with or without notice at any time at the option of either the Company or me. I understand that no manager or representative of the Company, other than the President of the Company, has any authority to enter into any agreements for employment for any specific period of time, or to make any agreement contrary to the foregoing.

4. My signature below 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. I further agree to furnish such additional information and complete such examinations as required to complete this application.

Do we have your permission to contact your previous employer and to run your DAC report?
Yes No

If you answer no, you will be contacted by a Flatbed Express Inc. personnel for further information.

Applicant's Electronic Signature:

Date:

Confidential Inquiry to Previous Employers

In accordance with FMCSR 49-391.23 and 49-382.413, I hereby authorize the above listed companies to release all records of employment, including assessments of my job performance, ability and fitness (including dates of any and all alcohol or drug tests, those confirmed results, and/or my refusal to submit to any alcohol or drug tests and any rehabilitation completion under direction of SAP/MRO) to each and every company (or their
authorized agents) which may request such information in connection with my application for employment with said company. I hereby release this company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing the following information to the above-mentioned person and/or company.

Applicant's Electronic Signature:

Date:

Pre-Employment Urinalysis Consent Form

I understand that as required by the Federal Motor Carrier Safety Regulations, Title 49 United States Code of Federal Regulations, Section 391.103, and company policy, all prospective drivers must submit to a controlled substances test.

A urine sample will be collected and tested for controlled substances.

I also understand that if I test positive for use of controlled substances, I am not medically
qualified to operate a commercial motor vehicle.

The results of the drug test will be maintained by the Medical Review Officer for the company who will report whether the test results were negative or positive, and if positive, the identity of the controlled substance for which the test was positive. The results will not be released to any additional parties without my written authorizations.

I hereby agree to submit to a drug screen urinalysis.

Applicant's Electronic Signature:

Date:

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