BS Carriers, LLC

PO BOX 3943

Gillette, WY 827

COMMERCIAL DRIVER APPLICANT INFORMATION

DATE        Position applying for:     Contractor        Driver    Contractor’s Driver

NAME         

PHONE (        )        EMERGENCY PHONE (        )        

AGE        DATE OF BIRTH        SS#         

(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.)

PHYSICAL EXAM EXPIRATION DATE         

CURRENT & PREVIOUS THREE YEARS ADDRESSES:

         FROM        TO         

         FROM        TO         

         FROM        TO         

HAVE YOU WORKED FOR THIS COMPANY BEFORE?        Yes                 No

If yes, give dates: From        To         

Reason for leaving?          

EDUCATION HISTORY:

Please circle the highest grade completed:

Grade school: 1 2  3  4 5  6  7 8  9  10  11 12

College: 1  2 3  4        Post Graduate: 1 2 3 4

EMPLOYMENT HISTORY:

Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years.

Mo/Yr        Mo/Yr        Present or Last Employer

From        To        Name         

Position Held        Address         

Reason for leaving        Company phone (        )         

Were you subject to the FMCSRs while employed here?        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

Mo/Yr        Mo/Yr        Present or Last Employer

From        To        Name         

Position Held        Address         

Reason for leaving        Company phone (        )         

Were you subject to the FMCSRs while employed here?        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

Mo/Yr        Mo/Yr        Present or Last Employer

From        To        Name         

Position Held        Address         

Reason for leaving        Company phone (        )         

Were you subject to the FMCSRs while employed here?        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

Mo/Yr        Mo/Yr        Present or Last Employer

From        To        Name         

Position Held        Address         

Reason for leaving        Company phone (        )         

Were you subject to the FMCSRs while employed here?        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

Mo/Yr        Mo/Yr        Present or Last Employer

From        To        Name         

Position Held        Address         

Reason for leaving        Company phone (        )         

Were you subject to the FMCSRs while employed here?        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

Mo/Yr        Mo/Yr        Present or Last Employer

From        To        Name         

Position Held        Address         

Reason for leaving        Company phone (        )         

Were you subject to the FMCSRs while employed here?        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

Mo/Yr        Mo/Yr        Present or Last Employer

From        To        Name         

Position Held        Address         

Reason for leaving        Company phone (        )         

Were you subject to the FMCSRs while employed here?        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

(Attach additional sheets for 10-year history, if needed.

DRIVING EXPERIENCE

List states operated in, for the last five (5) years:         

List special courses/training completed (PTD/DDC, HAZMAT, ETC)         

List any Safe Driving Awards you hold and from whom:         

Accident Record for past three (3) years: (attach sheet if more space is needed):

Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):

Driver’s License (list each driver’s license held in the past three(3) years:

Have you ever been denied a license, permit or privilege to operate a motor vehicle?        Yes                 No          Has any license, permit or privilege ever been suspended or revoked?                  Yes                   No 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)?

         Yes

         No

       Have you ever been convicted of a felony?                 Yes                 No

If the answers to any questions listed above are “yes”, give details         

Job References

List three (3) persons for references, other than family members, who have knowledge of your safety habits.

Name        Address        Phone         

Name        Address        Phone         

Name        Address        Phone         

To Be Read and Signed by Applicant:

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

It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person 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, I 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 application file.

It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I 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.

Applicant Signature        Date         

Remarks: (For office use only)