Application For Qualification
Company: Diamondback Services, Inc
Address: PO Box 28386
City: GladStone State: Missouri Zip Code: 64118
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 the Company named above.
Email address *
Digital Signature
This Acknowledgement and Certification of Understanding
("Acknowledgement") is to let you know that by submitting an electronic signature, you are
providing an electronic mark, that is held to the same standard as a legally binding equivalent of
a handwritten signature provided by you. For purposes of the acknowledgement, a digital mark
is considered a typed legal First and Last name (legal name may include middle name, initial or
suffix) followed by the typed date. Any document requiring an electronic signature may contain
a signature acknowledgment statement provided in the same area requiring the electronic
signature.
Date: *
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Name *
First and last name
Your answer
Phone number *
Your answer
Email
Your answer
Which position(s) are you interested in? *
Required
Age *
Your answer
Date of Birth *
MM
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DD
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YYYY
Social Security Number *
Your answer
Physical Exam Expiration Date *
MM
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DD
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Address History current and 3 years previous *
Address City State Zip Start/ End Dates
Your answer
Address History current and 3 years previous
Address City State Zip Start/ End Dates
Your answer
Address History current and 3 years previous
Address City State Zip Start/ End Dates
Your answer
Have you ever worked for this company before? *
If yes, give dates
Start Date and End Date
Your answer
Reason for leaving?
Your answer
Education History *
Please mark the box indicating the highest grade completed
1
2
3
4
5
6
7
8
9
10
11
12
Grade School
Education History
Please mark the box indicating the highest grade completed
1
2
3
4
College
Education History
Please mark the box indicating the highest grade completed
1
2
3
4
Post Graduate
Employment History
Give Complete Record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for past ten years.
Date: Month and Year *
Month/ Year to Month/ year
Your answer
Position Held *
Your answer
Employer Name, Address and phone number *
Employer Name: Address City State phone number
Your answer
Reason For Leaving *
Your answer
Where you subject to FMCSR's while employed here? *
Was your job designated as a safety - sensitive function in any DOT regulated mode subject to drug and alcohol testing? *
Date: Month and Year
Month/ Year to Month/ year
Your answer
Position Held
Your answer
Employer Name, Address and phone number
Employer Name: Address City State phone number
Your answer
Reason For Leaving
Your answer
Where you subject to FMCSR's while employed here?
Was your job designated as a safety - sensitive function in any DOT regulated mode subject to drug and alcohol testing?
Date: Month and Year
Month/ Year to Month/ year
Your answer
Position Held
Your answer
Employer Name, Address and phone number
Employer Name: Address City State phone number
Your answer
Reason For Leaving
Your answer
Where you subject to FMCSR's while employed here?
Was your job designated as a safety - sensitive function in any DOT regulated mode subject to drug and alcohol testing?
Date: Month and Year
Month/ Year to Month/ year
Your answer
Position Held
Your answer
Employer Name, Address and phone number
Employer Name: Address City State phone number
Your answer
Reason For Leaving
Your answer
Where you subject to FMCSR's while employed here?
Was your job designated as a safety - sensitive function in any DOT regulated mode subject to drug and alcohol testing?
Date: Month and Year
Month/ Year to Month/ year
Your answer
Position Held
Your answer
Employer Name, Address and phone number
Employer Name: Address City State phone number
Your answer
Reason For Leaving
Your answer
Where you subject to FMCSR's while employed here?
Was your job designated as a safety - sensitive function in any DOT regulated mode subject to drug and alcohol testing?
Date: Month and Year
Month/ Year to Month/ year
Your answer
Position Held
Your answer
Employer Name, Address and phone number
Employer Name: Address City State phone number
Your answer
Reason For Leaving
Your answer
Where you subject to FMCSR's while employed here?
Was your job designated as a safety - sensitive function in any DOT regulated mode subject to drug and alcohol testing?
Driving Experience *
Straight Truck (if none type none) Total number of miles
Your answer
Driving Experience *
Tractor Trailer including doubles/ triples and tanker (if none type none) Total number of miles
Your answer
Driving Experience *
Other (if none type none) Total number of miles
Your answer
List States operated in, for the last five years *
May abbreviate States
Your answer
Check Special courses/ training completed
Haz-Mat
Doubles
Triples
Tanker
Twic
Other
Row 1
List any Safe Driving Awards you hold and from whom:
Your answer
Accident Record for past three years
If none leave blank
Date of Accident
MM
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DD
/
YYYY
Type of Accident
(Head on, rear end, side swipe, hit stationary etc.)
Your answer
Location of Accident
Your answer
Fatalities
Injuries
Date of Accident
MM
/
DD
/
YYYY
Type of Accident
(Head on, rear end, side swipe, hit stationary etc.)
Your answer
Location of Accident
Your answer
Fatalities
Injuries
Date of Accident
MM
/
DD
/
YYYY
Type of Accident
(Head on, rear end, side swipe, hit stationary etc.)
Your answer
Location of Accident
Your answer
Fatalities
Injuries
Traffic Convictions for the last three years
Date: ______________Location:_____________________________ Charge:__________________ Penalty:
Your answer
Driver's License (list each License held in past three years) *
State,_______________ License Number_________________Class________Expiration Date ________________
Your answer
Have you ever been denied a license, permit or privilege to operate a motor vehicle? *
Has any license, permit or privilege ever been suspended or revoked? *
Is there any reason you might be unable to perform the functions of the job for which you have applied? *
Have you ever been convicted of a felony? *
If you answered yes to any of the above please give details.
Your answer
Personal References
Name: Address: Phone:
Your answer
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