USDOT# 2514703
484-767-9703
GS TRUCKING INC.
1500 FERRY STREET
EASTON, PA 18042
Custom solution developed by
GS
Trucking
Inc
Version 22092020
Copyright 2020-2020
www.gstruckinginc.com
DRIVER EMPLOYMENT APPLICATION
Name (first, middle, last)
Hire Date (office use only)
Address (street, city, state, zip code)
You must list all
previous addresses
for 3 years
Address (street, city, state, zip code)
Phone Number
Date of Birth
Social Security Number
*******Are you legally authorized to work in the U.S.?
Emergency Contact Name
Relation
Address
Phone Number
DRIVER LICENSE INFORMATION
Driver License Number
State
Type
Expiration Date
DRIVER EXPERIENCE
Type of Equipment
From (Date)
To (Date)
Approx # of Miles
Type of Equipment
From (Date)
To (Date)
Approx # of Miles
REQUIRED QUESTIONS
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?
Have you ever been convicted of any criminal act involving the use of a CMV or while driving a
CMV?
Have you ever been convicted of any serious crime?
(Include any plea of “Guilty” or “No Contest” except for minor traffic violation)
If you answered yes to any of the above 4 questions, you must attach a statement of explanation.
TICKETS / ACCIDENTS/ ETC. *write N/A if there is nothing to report
Accident Record for Past 3 Years
Date
Description
# of Injuries / Fatalities
Date
Description
# of Injuries / Fatalities
Traffic Convictions & Forfeitures for Past 3 Years
Date
Location
Charge
Penalty
Date
Location
Charge
Penalty
Page 1
USDOT# 2514703
484-767-9703
GS TRUCKING INC.
1500 FERRY STREET
EASTON, PA 18042
Custom solution developed by
GS
Trucking
Inc
Version 22092020
Copyright 2020-2020
www.gstruckinginc.com
EMPLOYMENT RECORD Applicant must include 10 years of any\all employment.
Begin with your most recent employer and work back until 10 years are included.
Employer
From (M/Y)
To (M/Y)
Reason for Leaving
Address
Phone
Position
Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT regulated mode
subject to the drug & alcohol testing requirements of 49 CFR part 40?
Employer
From (M/Y)
To (M/Y)
Reason for Leaving
Address
Phone
Position
Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT regulated mode
subject to the drug & alcohol testing requirements of 49 CFR part 40?
Employer
From (M/Y)
To (M/Y)
Reason for Leaving
Address
Phone
Position
Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT regulated mode
subject to the drug & alcohol testing requirements of 49 CFR part 40?
Employer
From (M/Y)
To (M/Y)
Reason for Leaving
Address
Phone
Position
Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT regulated mode
subject to the drug & alcohol testing requirements of 49 CFR part 40?
DECLARATION OF EMPLOYMENT STATUS (GAPS IN HISTORY)
If you were driving a CMV, you must provide complete employment history for the past 10 years.
Any gaps in employment longer than 1 month are explained as follows:
Activity During Break
From (M/Y)
To (M/Y)
In Addition, I was not employed by any company or individual
Activity During Break
From (M/Y)
To (M/Y)
In Addition, I was not employed by any company or individual
Activity During Break
From (M/Y)
To (M/Y)
In Addition, I was not employed by any company or individual
Page 2a
USDOT# 2514703
484-767-9703
GS TRUCKING INC.
1500 FERRY STREET
EASTON, PA 18042
Custom solution developed by
GS
Trucking
Inc
Version 22092020
Copyright 2020-2020
www.gstruckinginc.com
Employment History Continued
Employer
From (M/Y)
To (M/Y)
Reason for Leaving
Address
Phone
Position
Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT regulated mode subject
to the drug & alcohol testing requirements of 49 CFR part 40?
Employer
From (M/Y)
To (M/Y)
Reason for Leaving
Address
Phone
Position
Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT regulated mode subject
to the drug & alcohol testing requirements of 49 CFR part 40?
Employer
From (M/Y)
To (M/Y)
Reason for Leaving
Address
Phone
Position
Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT regulated mode subject
to the drug & alcohol testing requirements of 49 CFR part 40?
Employer
From (M/Y)
To (M/Y)
Reason for Leaving
Address
Phone
Position
Were you subject to the FMCSRs while employed?
Was your job designated as a safety sensitive function in any DOT regulated mode subject
to the drug & alcohol testing requirements of 49 CFR part 40?
DECLARATION OF EMPLOYMENT STATUS (GAPS IN HISTORY)
If you were driving a CMV, you must provide complete employment history for the past 10 years.
Any gaps in employment longer than 1 month are explained as follows:
Activity During Break
From (M/Y)
To (M/Y)
In Addition, I was not employed by any company or individual
Activity During Break
From (M/Y)
To (M/Y)
In Addition, I was not employed by any company or individual
Activity During Break
From (M/Y)
To (M/Y)
In Addition, I was not employed by any company or individual
For additional blocks needed, please make a copy of this form Page 2b
USDOT# 2514703
484-767-9703
GS TRUCKING INC.
1500 FERRY STREET
EASTON, PA 18042
Custom solution developed by
GS
Trucking
Inc
Version 22092020
Copyright 2020-2020
www.gstruckinginc.com
TO BE READ AND SIGNED BY APPLICANT
I authorize you, GS TRUCKING INC. , to make such investigations and inquiries of my personal, employment, financial or
medical history and other related matters as may be necessary in arriving at an employment decision. (Generally
inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I
hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and
releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or interviews may
result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company, as well as
the FMCSRs.
I understand information I provide regarding current and/or previous employers may be used, and those employers will be
contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23 (d) and (e). I
understand that I have the right to:
●
Review information provided by the previous employers;
●
Have errors in the information corrected by previous employers and for those previous employers to re-send the
corrected information to the prospective employer; and
●Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree
on the accuracy of the information.
This certifies 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
Print Name
Employer Witness Print Name
Witness Signature
Date
Page 3
USDOT# 2514703
484-767-9703
GS TRUCKING INC.
1500 FERRY STREET
EASTON, PA 18042
Custom solution developed by
GS
Trucking
Inc
Version 22092020
Copyright 2020-2020
www.gstruckinginc.com
ALCOHOL & CONTROLLED SUBSTANCE CONSENT AND RELEASE – applicant MUST answer:
Have you ever failed a pre-employment drug test, and as a result not been hired for a
DOT-regulated safety-sensitive position? (to include driving a CDL truck)
Have you ever refused to be tested for drugs or alcohol when required by the DOT,
including pre-employment?
If you answered “Yes” to either of the above questions, can you provide evidence of having
completed the return-to-duty process as described in part 40 of the DOT Regulations?
*Note to employer: If a person has failed a drug or alcohol test, or refused to be tested, at any time since 1994, he/she is
not eligible for employment in a safety-sensitive role unless they have completed the return to duty process.
If a person answers “yes” to either of the 1
st
two questions and cannot provide evidence of completion of the RTD
process, you have two options: do not hire, or do not hire until an initial SAP evaluation leading to a Return-to-Duty.
I understand that, as required by the Federal Motor Carrier Safety Regulations and company policy, all CDL drivers must
submit to alcohol and controlled substance testing as a condition of employment. Non-CDL drivers may also be subject to
testing per company policy. I also understand any offer of employment will be contingent upon the results of an alcohol
and controlled substance test.
Applicants for positions that require driving a commercial motor vehicle (CMV) requiring a CDL at any time will be required
to undergo controlled substances and at our discretion, alcohol testing prior to employment and will be subject to further
testing throughout their period of employment.
The company’s policy is that if a person has ever been in violation of the rules in part 40 (DOT) or 382 (FMCSA) they will
NOT be considered eligible for any job which includes operation of a CMV (Greater than 10,000 GVWR) unless they have
completed the return to duty process.
CDL drivers will be subject to random and reasonable suspicion drug testing each day they report for work.
Therefore, I agree to submit to the following alcohol and controlled substance tests in accordance and as defined by the
Federal Motor Carrier Safety Regulation and this company’s policies:
Pre-Employment, to determine employment eligibility
Random
Reasonable Suspicion
Post Accident
Follow Up (see company policy)
Return-to-duty (see company policy)
I certify that I have read, understand, and agree to abide by the condition of this consent and release form.
Failure to answer these questions and sign will prevent this employer from using you as a CMV operator.
Applicant Signature
Date
Print Name
Social Security Number
Employer Witness
Title
Page 4
USDOT# 2514703
484-767-9703
GS TRUCKING INC.
1500 FERRY STREET
EASTON, PA 18042
Custom solution developed by
GS
Trucking
Inc
Version 22092020
Copyright 2020-2020
www.gstruckinginc.com
CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS – PART 383
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate,
interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15
people, or transports hazardous materials that require placarding.
The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing
10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.
DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some
requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as
follows:
1.
You, as a commercial vehicle driver, may not possess more than one license.
2.
If you currently have more than one license, you should keep the license from your state of residence, and return
the additional licenses to the states that issued them. Destroying a license does not close the record in the state
that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, you should close
your record by notifying the state of issuance that you no longer want to be licensed by that state.
3.
Sections 392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer
the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Section 383.31
requires that any time you violate a state or local traffic law (other than parking), you must report it to your
employing motor carrier and the state that issued your license within 30 days.
DRIVER CERTIFICATION: I certify that I have read and understand the above requirements.
The following license is the only one I will possess:
Driver License Number
State
Expiration Date
Driver Signature
Date
Page 5
USDOT# 2514703
484-767-9703
GS TRUCKING INC.
1500 FERRY STREET
EASTON, PA 18042
Custom solution developed by
GS
Trucking
Inc
Version 22092020
Copyright 2020-2020
www.gstruckinginc.com
SAFETY PERFORMANCE HISTORY RECORDS REQUEST
Section 1
To be Completed by Prospective Employee (APPLICANT)
I, (first, middle, last)
Social Security Number
Date of Birth
Hereby Authorize (My Previous Employer):
Address (Street)
Phone
Address (City, State, Zip)
Fax
To release and forward the information requested by sections 2 & 3
of this document including my Alcohol and Controlled Substance Testing
records within the previous 3 years from :(M/Y of employment dates) to
To My Prospective Employer
GS TRUCKING INC.
Phone: 484-767-9703
Fax: 610-438-1941
Attn: Safety Manager
Address
1500 FERRY STREET, EASTON, PA 18042
In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures
confidentiality, such as fax, letter, or e-mail.
Applicant Signature
Date
Section 2
To be Sent to and Completed by the Previous Employer listed above
The applicant named above was employed by us
From M/Y
To M/Y
Did he/she drive a motor vehicle for you?
If yes, what type?
Straight Truck
Tractor Trailer
Other
Lay Off
Military Duty
Reason for leaving your employ
Discharged
Resignation
Accident History:
Complete the following for any accidents included on your accident register (§390.15(b)) involving the applicant
from the 3 years prior to the date signed above, or, if there is no accident register data for this driver,
Date
Location
No of Injuries
No of Fatalilities
Hazmat Spill
Date
Location
No of Injuries
No of Fatalilities
Hazmat Spill
Date
Location
No of Injuries
No of Fatalilities
Hazmat Spill
Please provide information concerning any other accidents involving the applicant that were reported to government
agencies or insurers or retained under internal company policies (per fmcsr 391.23)
Signature
Title
Date
A1
USDOT# 2514703
484-767-9703
GS TRUCKING INC.
1500 FERRY STREET
EASTON, PA 18042
Custom solution developed by
GS
Trucking
Inc
Version 22092020
Copyright 2020-2020
www.gstruckinginc.com
SAFETY PERFORMANCE HISTORY RECORDS REQUEST CONTINUED
Section 3
To be Completed by Previous Employer
If the applicant was NOT subject to
DOT testing requirements while employed by you please
fill in the dates of employment, complete the bottom of Section 3 sign, and return. M\Y to M/Y
Has this person had an alcohol test with a result of 0.04 or higher?
Has this person tested positive, adulterated or substituted a test specimen for controlled
substances?
Has this person refused to submit to a post accident, random, reasonable suspicion or follow
up controlled substance test?
Has this person committed other violations of Subpart B of Part 382 or Part 40?
If this person has violated a DOT drug & alcohol regulation did this person complete a SAP
prescribed rehabilitation program in your employ, including return-to-duty and follow-up
tests? If yes, please send documentation with this form.
For a driver who successfully complete a SAP’s rehabilitation referral and remained in your
employ, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified
positive drug test, or refuse to be tested?
In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previous
employers in the previous 3 years prior to the application date shown in Section 1.
Previous Employer Representative Name (Print)
Previous Employer Company
Phone
Address (Street, City, State, Zip)
Signature
Date
Section 4
To be Completed by Prospective Employer
1.This form was
Faxed
Mailed
Other
By (sign)
On (Date)
2.This form was
Faxed
Mailed
Other
By (sign)
On (Date)
3.This form was
Faxed
Mailed
Other
By (sign)
On (Date)
Information was received:
On: (Date)
By Fax
By Mail
By Other
A2
USDOT# 2514703
484-767-9703
GS TRUCKING INC.
1500 FERRY STREET
EASTON, PA 18042
Custom solution developed by
GS
Trucking
Inc
Version 22092020
Copyright 2020-2020
www.gstruckinginc.com
General Consent for Limited Queries
of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse
I, (driver name) , hereby provide consent to
(employer name) GS TRUCKING INC.
to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse
(Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse.
This shall include consent of initial inquiry, as well as annual queries (if applicable) required by FMCSA
for the duration of my employment.
I understand that if a limited query conducted by
(employer name) _GS TRUCKING INC. indicates that drug or alcohol violation information about me exists in the
Clearinghouse, FMCSA will not disclose that information to (employer name) _GS TRUCKING INC.
obtaining additional specific consent from me.
I further understand that if I refuse to provide consent for (employer name) GS TRUCKING INC.
without first
to conduct a
limited query of the Clearinghouse, (employer name) GS TRUCKING INC. must prohibit me from performing
safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol
program regulations.
Employee Signature
(date)
B1
USDOT# 2514703
484-767-9703
GS TRUCKING INC.
1500 FERRY STREET
EASTON, PA 18042
Custom solution developed by
GS
Trucking
Inc
Version 22092020
Copyright 2020-2020
www.gstruckinginc.com
HOURS OF SERVICE RECORD (7 DAY SHEET)
FOR FIRST TIME OR INTERMITTENT DRIVERS
On the first day you drive, you must fill out this form to record all work from the previous week done for direct or indirect
compensation.
Name:
Employee ID#:
Location:
Date
Total Time on Duty
Time Relieved from duty
(7 days ago)
(6 days ago)
(5 days ago)
(4 days ago)
(3 days ago)
(2 days ago)
(Yesterday)
(Today’s Date)
I hereby certify that the information contained hereon is true and to the best of my knowledge and belief, and that my last
period of release from duty was:
From (Date)
To (Date)
Signature
Date
Time
C1
USDOT# 2514703
484-767-9703
GS TRUCKING INC.
1500 FERRY STREET
EASTON, PA 18042
Custom solution developed by
GS
Trucking
Inc
Version 22092020
Copyright 2020-2020
www.gstruckinginc.com
DRIVER HIRING ROAD TEST
PART A – TEST
Drivers Name
Phone Number
Address
City, State Zip
Rating of Performance
The pre-trip inspection (as required by Sec. 392.7) :
Coupling and uncoupling of combination units, if the equipment he or she may drive includes combination units :
Placing the equipment in operation :
Use of vehicle’s controls and emergency equipment :
Operating the vehicle in traffic and while passing other vehicles :
Turning the vehicle :
Braking and slowing the vehicle by means other than braking :
Backing and parking the vehicle :
Other: Explain:
Type of Equipment used in giving test
Examiners Signature
Date
PART B - CERTIFICATION OF ROAD TEST
Driver’s Name
Social Security Number
License Number
State
Type of Power Unit
Type of Trailer
If a passenger carrier, type of bus
Signature of Examiner
Title
This is to certify that the above-named driver was given a
road test under my supervision on (date)
consisting of approximately miles of driving. It
is my considered opinion that this driver possessed
sufficient driving to operate safety in the type of
commercial motor vehicle listed above.
Organization and Address of Examiner
D1
USDOT# 2514703
484-767-9703
GS TRUCKING INC.
1500 FERRY STREET
EASTON, PA 18042
Custom solution developed by
GS
Trucking
Inc
Version 22092020
Copyright 2020-2020
www.gstruckinginc.com
PART B – MVR (Attach MVR to form)
PART C – CARRIER’S ANNUAL REVIEW
ANNUAL REVIEW OF DRIVING RECORD
PART A – CERTIFICATION OF VIOLATIONS
Driver Name
MOTOR CARRIER INSTRUCTIONS: The Company is required by the DOT to perform an annual records check, to
ensure the company is aware of any and all traffic violations committed by its drivers, including those in a private auto as
well as any in a Commercial Motor Vehicle.
Please list on the following lines all violations of motor vehicle traffic laws and ordinances (other than violations for parking
only) of which you have been convicted, or on account of which you have forfeited bond or collateral during the last 12
months. (Per FMCSR 391.27)
I certify that the following is a true and complete list of traffic violations required to be listed for which I have been
convicted or forfeited bond or collateral during the past 12 months.
| Date | Offense | Location | Type of Vehicle Operated |
If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any
violation (other than those I have provided under Part 383) required to be listed during the past 12 months.
Driver’s license #:
Change of Address:
If you have moved in the last 12 months, provide your new address here
State: Exp. Date:
Drivers Signature Today’s Date
Carrier’s annual review of driving record and certification of continued qualification as required by FMCSR 391.25(c)(2)
This day I have reviewed the driving record of the above named driver in accordance with 391.25 of the FMCSRs. I
considered any evidence that the driver has violated applicable provisions of the FMCSRs and the HMRs (if applicable). I
considered the driver’s accident record and any evidence that he/she has violated any laws governing the operation of
motor vehicles, and gave great weight to violations, such as speeding, reckless driving, and operation while under the
influence of alcohol or controlled substances, that indicate the driver has exhibited a disregard for the safety of the public.
Having done so, I find that:
The driver meets the minimum requirements for safe driving, or
The driver is disqualified to drive a CMV pursuant to 391.15., or
This driver is disqualified to drive a CMV pursuant to company policy
Carrier’s Name
GS TRUCKING INC.
Carrier’s Address
1500 FERRY STREET, EASTON, PA 18042
Reviewed by:
Title
Date
E1