Driver Application | Elite Transportation Systems

Driver

Application

Independent Contractor Application

ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC. ELITE TRANSPORTATION SYSTEMS, INC.

Select your vehicle weight rating:

Car / Pickup / Sprinter

(UNDER 10K GVWR)

Docks / Flatbeds / Semis

(OVER 10K GVWR)

UNDER 10,000 GVWR – Independent Contractor Application

Step 1 of 3

33%

URL

This field is for validation purposes and should be left unchanged.

01.

UNDER 10K GVWR – CONTRACTOR APPLICATION

Personal Information

Elite Transportation Systems, Inc. | 9113 Davenport St NE, Blaine, MN 55449

Today's Date(Required)

Name

First Name(Required)

Middle Name

Last Name(Required)

Cell Phone(Required)

Home Phone

Email(Required)

Current Address

Address(Required)

Street Address Address Line 2 City State ZIP Code

How Long at This Address?(Required)

How Many Previous Addresses Would You Like to Add?

Previous Address 1

Address

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 1?

Previous Address 2

Address

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 2?

Previous Address 3

Address

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 3?

Previous Address 4

Address

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 4?

Previous Address 5

Address

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 5?

Previous Address 6

Address

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 6?

Required by Department of Transportation

Are You a US Citizen?(Required)

Work Eligibility(Required)

Date of Birth(Required)

Have You Ever Been Convicted of a Crime?(Required)

Served in Armed Forces?

If yes, please explain

Primary Driver's License

What Type of Driver's License Do You Have?(Required)

DL State(Required)

DL Number(Required)

DL Expiration Date(Required)

Any accidents in a commercial vehicle in the last three years?(Required)

Yes

If Yes — How Many Accidents?

If Yes — Please Explain Accidents

Have you had any moving violations during the last three years?(Required)

Yes

If Yes — How Many Violations?

If Yes — Please Explain Violations

Have you ever had any driver's license denied, suspended, revoked, or canceled by any issuing state agency?(Required)

Yes

If Yes — State of Issuance and Explanation

History of Work

Most recent job listed first. DOT requires 3 years of driving history and 10 years history for larger vehicles. Drivers of vehicles rated over 26,000 GVW must list at least the last 10 years’ per FMCSR §383.35(c).

Employer 1

Employer 1 — Name

Employer 1 — From

Employer 1 — To

Employer 1 — Supervisor

Employer 1 — Supervisor Email

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer 1 — Telephone

Employer 1 — Fax

Employer 1 — Position / Duties

Employer 1 — Were you subject to Federal Motor Carrier Safety Regulations during this period?

Yes

Employer 1 — Were you subject to 49 CFR Part 40 controlled substance and alcohol testing during this period?

Yes

How Many Additional Employers Would You Like to Add?

Employer 2

Employer 2 — Name

Employer 2 — From

Employer 2 — To

Employer 2 — Supervisor

Employer 2 — Supervisor Email

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer 2 — Telephone

Employer 2 — Fax

Employer 2 — Position / Duties

Employer 2 — Were you subject to Federal Motor Carrier Safety Regulations during this period?

Yes

Employer 2 — Were you subject to 49 CFR Part 40 controlled substance and alcohol testing during this period?

Yes

Employer 3

Employer 3 — Name

Employer 3 — From

Employer 3 — To

Employer 3 — Supervisor

Employer 3 — Supervisor Email

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer 3 — Telephone

Employer 3 — Fax

Employer 3 — Position / Duties

Employer 3 — Were you subject to Federal Motor Carrier Safety Regulations during this period?

Yes

Employer 3 — Were you subject to 49 CFR Part 40 controlled substance and alcohol testing during this period?

Yes

Employer 4

Employer 4 — Name

Employer 4 — From

Employer 4 — To

Employer 4 — Supervisor

Employer 4 — Supervisor Email

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer 4 — Telephone

Employer 4 — Fax

Employer 4 — Position / Duties

Employer 4 — Were you subject to Federal Motor Carrier Safety Regulations during this period?

Yes

Employer 4 — Were you subject to 49 CFR Part 40 controlled substance and alcohol testing during this period?

Yes

Employer 5

Employer 5 — Name

Employer 5 — From

Employer 5 — To

Employer 5 — Supervisor

Employer 5 — Supervisor Email

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer 5 — Telephone

Employer 5 — Fax

Employer 5 — Position / Duties

Employer 5 — Were you subject to Federal Motor Carrier Safety Regulations during this period?

Yes

Employer 5 — Were you subject to 49 CFR Part 40 controlled substance and alcohol testing during this period?

Yes

Employer 6

Employer 6 — Name

Employer 6 — From

Employer 6 — To

Employer 6 — Supervisor

Employer 6 — Supervisor Email

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer 6 — Telephone

Employer 6 — Fax

Employer 6 — Position / Duties

Employer 6 — Were you subject to Federal Motor Carrier Safety Regulations during this period?

Yes

Employer 6 — Were you subject to 49 CFR Part 40 controlled substance and alcohol testing during this period?

Yes

For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).

Certification & Signature

“I certify that this information sheet was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. Willfully providing false information may result in termination of my contract(s).”

Full Name(Required)

Today's Date(Required)

Signature(Required)

Your Name

02.

EQUIPMENT INFO, WORK SURVEY & HEALTH CARD

Name

First Middle Last

Vehicle

Year

Make

Model

Color

# Axels

Trailer

Type

Year

Make

Model

Length

Width

Load Capacity

# Axels

Work Survey

What days are you available for work?

Are you available between 6 am and 6 pm?

YES

What is the goal for your earnings?

Health Card = Medical Examiners Certificate

Do you have a current DOT Health Card?

YES

Expiration Date

Do you require a DOT Medical Waver?

YES

Please Explain

03.

DISCLOSURE & AUTHORIZATION TO RELEASE INFORMATION

I am aware that a consumer report, (motor vehicle record) will be obtained on me in the course of consideration for contract and at times throughout my contract.
I hereby authorize procurement of consumer report(s). If contracted, this authorization shall remain on file and serve as ongoing authorization for you to procure consumer reports at any time during my contract period.
I hereby authorize procurement of background check information including, but not limited to; local, county, state and national criminal background checks. This authorization shall remain in effect for the period of my qualification process up to one year from the date of this form and, if contracted, throughout the entire period of my contract.

Drivers License Number

State of Drivers License

Address

Street Address Address Line 2 City State ZIP Code

Full Name(Required)

Today's Date(Required)

Signature(Required)

Your Name

Over 10,000 GVWR – Independent Contractor Application

Step 1 of 5

20%

Name

This field is for validation purposes and should be left unchanged.

01.

OVER 10K GVWR – CONTRACTOR APPLICATION

Personal Information

Elite Transportation Systems, Inc. | 9113 Davenport St NE, Blaine, MN 55449

Today's Date(Required)

Name

First Name(Required)

Middle Name

Last Name(Required)

Cell Phone(Required)

Home Phone

Email(Required)

Current Address

Address(Required)

Street Address Address Line 2 City State ZIP Code

How Long at This Address?(Required)

How Many Previous Addresses Would You Like to Add?

Previous Address 1

Address

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 1?

Previous Address 2

Address

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 2?

Previous Address 3

Address

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 3?

Previous Address 4

Address

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 4?

Previous Address 5

Address

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 5?

Previous Address 6

Address

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 6?

Required by Department of Transportation

Are You a US Citizen?(Required)

Work Eligibility(Required)

Date of Birth(Required)

Have You Ever Been Convicted of a Crime?(Required)

Served in Armed Forces?

If yes, please explain

Primary Driver's License

What Type of Driver's License Do You Have?(Required)

DL State(Required)

DL Number(Required)

DL Expiration Date(Required)

Any accidents in a commercial vehicle in the last three years?(Required)

Yes

If Yes — How Many Accidents?

If Yes — Please Explain Accidents

Have you had any moving violations during the last three years?(Required)

Yes

If Yes — How Many Violations?

If Yes — Please Explain Violations

Have you ever had any driver's license denied, suspended, revoked, or canceled by any issuing state agency?(Required)

Yes

If Yes — State of Issuance and Explanation

History of Work

Most recent job listed first. DOT requires 10 years work history for drivers of vehicles rated over 10,001 GVW. Must list at least the last 10 years’ per FMCSR §383.35(c).

Employer 1

Employer 1 — Name

Employer 1 — From

Employer 1 — To

Employer 1 — Supervisor

Employer 1 — Supervisor Email

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer 1 — Telephone

Employer 1 — Fax

Employer 1 — Position / Duties

Employer 1 — Were you subject to Federal Motor Carrier Safety Regulations during this period?

Yes

Employer 1 — Were you subject to 49 CFR Part 40 controlled substance and alcohol testing during this period?

Yes

How Many Additional Employers Would You Like to Add?

Employer 2

Employer 2 — Name

Employer 2 — From

Employer 2 — To

Employer 2 — Supervisor

Employer 2 — Supervisor Email

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer 2 — Telephone

Employer 2 — Fax

Employer 2 — Position / Duties

Employer 2 — Were you subject to Federal Motor Carrier Safety Regulations during this period?

Yes

Employer 2 — Were you subject to 49 CFR Part 40 controlled substance and alcohol testing during this period?

Yes

Employer 3

Employer 3 — Name

Employer 3 — From

Employer 3 — To

Employer 3 — Supervisor

Employer 3 — Supervisor Email

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer 3 — Telephone

Employer 3 — Fax

Employer 3 — Position / Duties

Employer 3 — Were you subject to Federal Motor Carrier Safety Regulations during this period?

Yes

Employer 3 — Were you subject to 49 CFR Part 40 controlled substance and alcohol testing during this period?

Yes

Employer 4

Employer 4 — Name

Employer 4 — From

Employer 4 — To

Employer 4 — Supervisor

Employer 4 — Supervisor Email

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer 4 — Telephone

Employer 4 — Fax

Employer 4 — Position / Duties

Employer 4 — Were you subject to Federal Motor Carrier Safety Regulations during this period?

Yes

Employer 4 — Were you subject to 49 CFR Part 40 controlled substance and alcohol testing during this period?

Yes

Employer 5

Employer 5 — Name

Employer 5 — From

Employer 5 — To

Employer 5 — Supervisor

Employer 5 — Supervisor Email

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer 5 — Telephone

Employer 5 — Fax

Employer 5 — Position / Duties

Employer 5 — Were you subject to Federal Motor Carrier Safety Regulations during this period?

Yes

Employer 5 — Were you subject to 49 CFR Part 40 controlled substance and alcohol testing during this period?

Yes

Employer 6

Employer 6 — Name

Employer 6 — From

Employer 6 — To

Employer 6 — Supervisor

Employer 6 — Supervisor Email

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer 6 — Telephone

Employer 6 — Fax

Employer 6 — Position / Duties

Employer 6 — Were you subject to Federal Motor Carrier Safety Regulations during this period?

Yes

Employer 6 — Were you subject to 49 CFR Part 40 controlled substance and alcohol testing during this period?

Yes

Certification & Signature

Full Name(Required)

Today's Date(Required)

Signature(Required)

Your Name

02.

EQUIPMENT INFO, WORK SURVEY & HEALTH CARD

Name

First Middle Last

Vehicle

Year

Make

Model

Color

# Axels

Trailer

Type

Year

Make

Model

Length

Width

Load Capacity

# Axels

Work Survey

What days are you available for work?

Are you available between 6 am and 6 pm?

YES

What is the goal for your earnings?

Health Card = Medical Examiners Certificate

Do you have a current DOT Health Card?

YES

Expiration Date

Do you require a DOT Medical Waver?

YES

Please Explain

03.

DISCLOSURE & AUTHORIZATION TO RELEASE INFORMATION

I am aware that a consumer report, (motor vehicle record) will be obtained on me in the course of consideration for contract and at times throughout my contract.

I hereby authorize procurement of consumer report(s). If contracted, this authorization shall remain on file and serve as ongoing authorization for you to procure consumer reports at any time during my contract period.

I hereby authorize procurement of background check information including, but not limited to; local, county, state and national criminal background checks. This authorization shall remain in effect for the period of my qualification process up to one year from the date of this form and, if contracted, throughout the entire period of my contract.

Drivers License Number

State of Drivers License

Address

Street Address Address Line 2 City State ZIP Code

Full Name(Required)

Today's Date(Required)

Signature(Required)

Your Name

04.

INQUIRY INTO CDL HISTORY, PRECEDING 3 YEARS

The Federal Motor Carrier Safety Regulations require all previous employers of this applicant to respond to this request for information within 30 days. Failure to comply with this request is in violation of 49CFR 391.23 and 40.25, for which you may be prosecuted. Questions concerning the requirements of this regulation should be directed to the Minnesota Division Office of the Federal Motor Carrier Safety Administration at 651-291-6150 during business hours.
TO:

_________________________________ ___________________
Former Employer’s Name Date:

_________________________________
Mailing Address

_________________________________
City/State/Zip

________________ _________________
Telephone # Fax #

I, ____________________________________, hereby authorize ________________________ to release all records of employment, including assessments of my job performance, ability, and fitness, including the dates of any and all alcohol or drug tests, with confirmed results, and/or my refusal to submit to any alcohol and drug tests and any rehabilitation completion under direction of Substance Abuse Professional (SAP) and/or Medical Review Officer (MRO) to each and every company (or their authorized agents) making such request in connection with my application for employment with said company. I hereby release the above named company and its employees, officers, directors and agents from any an all liability of any type as a result of providing the following information to the below mentioned person and/or company

NOTE: For this page you only need to sign and date

Full Name(Required)

Today's Date(Required)

Signature(Required)

Your Name

REQUEST FROM:

Company: Elite Transportation Systems, Inc
Address: 9113 Davenport Street NE, Blaine, MN 55449
Telephone: 763-785-4004
Contact person & Title: Doug Millard, Fleet Services __________________________________________
NAME OF APPLICANT: __________________________________ SSN: _________________________
Job applying for: Driver

INQUIRY INTO EMPLOYMENT HISTORY, PRECEDING 3 YEARS

Did applicant work for you as a from / / to / / ? YES NO

If NO, please explain: _________________________________________________________

If employed as a driver, please answer the following: Company driver? _______________Owner/Operator? _____ Other? __________
Type of truck(s) and/or truck/tractor(s) operated: _______________________

Accidents? YES or NO If YES, please give date(s) and brief description of each accident:

_____________________________________________________________________________

Why did this employee leave your company?

_____________________________________________________________________________

Would you re-employ this person? YES or NO If NO, please explain:

_____________________________________________________

Additional comments:

______________________________________________________________________________

INQUIRY FOR ALCOHOL AND CONTOLLED SUBSTANCES INFORMATION, PRECEDING 2 YEARS

Alcohol tests with a result of 0.04 or greater? YES or NO If YES, please give date(s): _________________
Verified positive controlled substance test results? YES or NO If YES, please give date(s): _________________
Refusals to be tested? YES or NO If YES, please give date(s): _________________
Was rehabilitation completed as required? YES or NO If YES, please give date(s): _________________

Person providing the above information:

Name: __________________________________ Title: ________________________ Company: __________________________ Date: ________________________

05.

PSP ONLINE SERVICE DISCLOSURE & AUTHORIZATION

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Elite Transportation Systems (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I Authorize Elite Transportation Systems (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.

I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

Full Name(Required)

Today's Date(Required)

Signature(Required)

Your Name

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49 C.F.R. 383.5.

_{LAST UPDATED 2/11/2016}