Employment Application

Driver Job Description Acknowledgement
Date*
My printed name and date indicate that I have read, understand and believe that I am able to perform the essential functions of the Driver job description presented during the applications process with Skagit Transportation, Inc. Do you require accommodations?
Do you require accommodations?*
- Yes
- No
Please give your recommendations as to what accommodations would enable you to perform the essential functions

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Periods of Unemployment for 30 days or more (Periods of unemployment will not necessarily disqualify you)
From Month/Year To Month/Year Reason
May we contact your present employer?*
- Yes
- No
(optional) List any skills or abilities you have which are pertinent to the position, including hobbies, special interests and membership in clubs or organizations (exclude organizations which may indicate your race, religion, sex, color, marital status, national origin, age, disability or other protected status).
Personal References*
List at least 3 persons to whom you are not related and by whom you have not been employed. These people should have known you for several years.
Name Address Telephone Number Occupation

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Driver's Rights Pertaining to Release of Driver Information Under Regulation 391.23
Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of that motor carrier for a continuous period which began before January 1, 1971.
- An inquiry into the driver's driving record during the preceding three years to the appropriate agency of every state in which the driver held a motor vehicle operator's license or permit during those three years; and
- An investigation of the driver's employment record during the preceding three years.
- A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed on the Driver Qualification File within 30 days of the date the driver's employment begins and be retained in compliance with 391.51.
- Replies to the investigations of the driver's safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver's employment begins. This goes into effect after October 29, 2004.
- Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.
- Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.
Drivers have the following rights:
1. The right to review information provided by previous employers
2. The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer.
3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
Drivers who wish to review previous employer provided investigative information must submit a written request to the prospective employer when applying of as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver's request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the Driver's Safety Performance History.
To Be Read and Signed By Applicant
It is agreed and understood that any misrepresentation given to this application shall be considered an act of dishonesty.

It is agreed and understood that Skagit Transporation, Inc. or our agents 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 releases employers and persons named herein from all liability for any damages on account of his/her 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 regard 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 for Qualification in no way obliges Skagit Transportation, Inc. to employ or hire me.

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.*
- Check Box To Agree to Terms Above
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Drivers License Number*
License State*
Expires*
Date Format: MM slash DD slash YYYY

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Class of Equipment	Equipment Type (Flat, Van, Etc.)	From	To	Approx. Total Miles

Date	Nature of Accident	Fatalities	Injuries

Location	Date	Charge	Penalty

Step 1 of 7

Driver Job Description Acknowledgement

Personal Data

Education

Licenses / Driving Experience

Employment

Job Listing 2

Job Listing 3

Job Listing 4

Driver's Rights Pertaining to Release of Driver Information Under Regulation 391.23

To Be Read and Signed By Applicant

License State	License Number	License Type	Expiration Date

From Month/Year	To Month/Year	Reason

Name	Address	Telephone Number	Occupation