Driver Application

Before starting, it's a good idea to gather your previous employer and driving history info for the past 10 years

Good news - your information is saved as you go, so if you get disconnected or need to stop at any time, easily return later and pick up where you left off just by clicking the 'Start My Application' button

First Name

Last Name

Email Address

Phone #

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General Information

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Terminal You Are Applying With How You Heard About Us

Enter first name, last name, and middle name as reflected on your driver's license

First Name

Middle Name

Last Name

Birth Date

SSN

Federal ID#

Cell Phone #

Street Address

City

State

Zip Code

Years At Address

Months

Email Address

Gender

Male Female

Emergency Contact

Phone #

Relationship

Last School Grade

Last School Name

Last Year

Prior Addresses - If you have been at your current address less than three (3) years, please list all previous addresses you have lived at for the last three (3) years

Street Address	City	State	Zip	Years Here	Months Here

Driving History

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Driver License #

State

Type/Class

Expiration Date

Motor Vehicle Years Motor Vehicle Months

Commercial Vehicle Years Commercial Vehicle Months

Tractor-Trailer Years Tractor-Trailer Months

OTR Years OTR Months

City Driving Years City Driving Months

Makes Of Tractors Driven

Twin Screw Single Axle Conventional Sleeper COE

Transmission Types

Types Of Trailers 35 foot 40 foot Other

Freight Hauled General Refrigerated Steel Hazardous Tanker

Other

Employment History

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Please Indicate The Last 10 Years Of Employment History

Company Name

Address

City, State, Zip

Position

Supervisor

Phone #

Started Ended

Reason For Leaving

Required Class A CDL

Under Rules Of FMCSR

Test For Drugs/Alcohol

Row#	Company name	Start Date	End Date

Company Name	Street Address	City, State Zip	Position	Supervisor	Phone #	Start Date	End Date	Reason For Leaving	Required Class A CDL	Under Rules Of FMCSR	Tested For Drugs/Alcohol	Delete

General Questions

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Please Check All That Apply

Possess A Valid U.S. Department Of Transportation Long Form Physical Have Received A Safe Driving Award

Have Received Worker's Compensation Defects In Hearing

Defects In Vision Defects In Speech

Had Any Physical/Mental Disorders That Would Disqualify You From Driving Under DOT Regulations Discharged By An Employer Due To An Accident

Been Convicted Of Any Crime/Felony Been Known By Any Name Other Than The One On This Application

Tested Positive Or Refused To Test On Any Pre-Employment Alcohol/Drug Test Administered By An Employer To Which You Applied But Were Not Hired During The Past 2 Years License Has Been Revoked, Suspended, Or Denied In Any State

If Any Of The Above Items Were Checked, Please Explain Each And Every Item Checked

It is agreed and understood that Genesis Worldwide LLC and its 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. The applicant agrees to furnish such additional information and complete such examinations as may be required to complete his/her file. It is agreed and understood that this application in no way obligates to approve the application. However, it is agreed and understood that if approved, the applicant may be on a probationary period during which time he/she may be released 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.

Convictions/Accidents/Tickets

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List Convictions Or Forfeiture Of Bond, If Any, For Violation Of Any Criminal Law

Offense

Date

City & State

Disposition

Row#	Offense	Date	City & State	Disposition

Offense	Date	City & State	Disposition	Delete

List All Vehicular Accidents For The Past Three (3) Years, Preventable Or Non-Preventable, In Which You Were Involved

Date

City & State

Description

Vehicle Type

Injuries

Row#	Date	City & State	Description	Vehicle Type	Injuries

Date	City & State	Description	Vehicle Type	Injuries	Delete

List Any And All Ticketets Or Arrests For Any Motor Vehicle Law Violations For The Past Three (3) Years

Violation

Date

City & State

Fine/Bond

Disposition

Row#	Violation	Date	City & State	Fine/Bond	Disposition

Violation	Date	City & State	Fine/Bond	Disposition	Delete

Occupational/Accident Insurance

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If you wish to purchase occupational/accident insurance (at a cost to you), please enter beneficiary name and relation. If not, please select that you are waiving this coverage below.

Beneficiary Name Beneficiary Relationship

It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

In providing the information, I understand and hereby state that:

1. to the best of my knowledge and belief, all information on this Form is complete and truthful;
2. this coverage is not a contract for Statutory Worker's Compensation Insurance, and neither I nor my carrier become participants in the Worker's Compensation system by purchasing this insurance; and
3. if, based on the information supplied in this Form, I am not eligible for coverage, premium will be refunded and no claims will be payable.

I also authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company or any other organization, institution or person that has any records, including any medical records, to furnish such information or copies of records to Atlantic Specialty Insurance Company, the motor carrier or the motor carrier's designee. A photographic copy of this information shall be as valid as the original.

IF THE INFORMATION PROVIDED IN THIS FORM IS FRAUDULENT, THE INSURER HAS THE RIGHT TO RETURN PREMIUM AND CANCEL COVERAGE

In order to verify the information provided in this Form, I give the Insurer authority to examine the records that are maintained by the motor carrier.

I certify that I am an independent contractor, paid by 1099 tax form, not as a W-2 employee.

Payment Authorization: I authorize the above named motor carrier, with whom I have a contract, to take monthly deductions, equal to my premiums, from my settlement account on behalf, and to remit these to Atlantic Specialty Insurance Company.

I UNDERSTAND THAT THE COST OF THE INSURANCE IS MY SOLE OBLIGATION AND RESPONSIBILITY, regardless of the above arrangement of premium payment. I agree that I will forward any amount due and owing to Atlantic Specialty Insurance Company, upon demand, for any insurance at any time my account remains unpaid.

Agreements

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Click Here To View Safety Policies And Procedures

I certify that I have read and understand the Company Statement of Policy on Drug and Alcohol Abuse and have received a copy of that policy. By accepting employment of qualification or contractual agreement with the Company, I also consent to submit to screening for drugs and/or alcohol and controlled substances and I agree to comply with all of the requirements of the Company, the Federal Motor Carrier Safety Regulations and my federal, state, or local laws and rules governing the use or abuse of alcohol, drugs and controlled substances. I understand that my failure to honor the terms of this agreement will be grounds for termination of my qualification, and/or my contractual agreement with the Company.

FMCSA Notification of Driver Rights

In compliance with 49 CFR Part 391.23, you have certain rights regarding the performance history information that will be provided to prospective employers.
    I) You have the right to review information provided by previous employers.
   II) You have the right to have errors in the information corrected by the previous employer and for the previous employer to re-send the corrected information to prospective employers.
  III) You have 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.
(2) Drivers who have previous DOT regulated employment history in the preceeding three years and wish to review previous employer-provided investigative information must submit a written request to prospective employers. This may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. Prospective employers must provide this information within five business days of receiving the written request. If prospective employers have not yet received the requested information from the previous employer, then the five day deadline will begin when the requested safety performance history information is received. If you have not arranged to pick up or receive the requested records within 30 days of prospective employers making them available, prospective employers may consider you to have waived your request to review the record.

Rules And Procedures

This is to certify that I have been through orientation on the following rules, regulations, and procedures and that I have received EAP training on controlled substances:
    DRUG AND ALCOHOL ABUSE POLICY AND EDUCATION
    UNAUTHORIZED PASSENGERS
    LOG AND HOURS OF SERVICE REGULATION
    VEHICLE INSPECTION PROCEDURES
    HAZARDOUS MATERIALS AND REGULATIONS
This is to certify that I have received and do fully understand the rules and procedures for Independent Contractors. I have also had compensation procedures explained and I understand them.
I acknowledge receipt of the Federal Motor Carrier Safety Regulations, and I agree to familiarize myself with parts 325, 382, 383, 386, 387 and 390-399 Subchapter 3, Chapter 3, Title 49 of the Code Of Federal Regulations.
According to the D.O.T. interpretations, every carrier must adopt and enforce a MEAL STOP POLICY in accordance with Line #1, OFF-Duty, and maintain a copy of this policy with the driver's signature in his/her personnel file. One (1) hour off-duty is allowed for a meal stop in ten (10) hour driving period. This may be taken in two (2) one-half (1/2) hour segments.
I DO ACKNOWLEDGE THAT I HAVE READ AND DO UNDERSTAND THE ABOVE POLICIES AND PROCEDURES. I FURTHER UNDERSTAND THAT NON-COMPLIANCE AND/OR VIOLATIONS OF ANY OF THE ABOVE RULES WILL RESULT IN IMMEDIATE CORRECTIVE ACTION.

Log Policies

In our ongoing attempt to keep our company's safety standards, we are asking for your support. Please be aware that the safety department audits roadside inspections and logs to improve standards and have set new goals for us to meet. When completing a driver log, please make sure that the following are all marked as on-duty statuses:
    Drivers are logging fuel stops, logging "fuel" and the city
    Drivers are logging DOT roadside inspections, logging "DOT inspections" and the city
    Drivers are logging Random Drug Screen time
    Drivers are logging in and out gate times and the city

We feel that keeping logs up to date and accurate is a major step toward reducing out-of-service violations on roadside inspections. We are monitoring for major violations and repeat offenders, and if deemed necessary, we will spend a day training said violators. Also, a trend has been noticed: Many drivers are not taking the 10 consecutive hours off duty to reset the 14-hour clock. This leads to hours of service violations. Understand that this is to reduce the likelihood of being inspected by a DOT official. Also be advised that drivers need to turn a copy of the roadside into corporate. Otherwise, we order the reports from the state for a fee. The fee will be charged back to the driver. Please have all drivers sign and return this form, acknowledging our goals and expectations.

Safety Policy

The efficiency of any operation can be measured directly by its ability to control loss. Accidents resulting in personal injury, damage to property and equipment represents needless suffering and waste. It is the responsibility of the management of this company to assure the safest conditions and equipment for all employees. The company policy on safety is:
   (1) The safety of the employees, public and the operations is paramount. Every effort will be made to eliminate hazards and reduce the possibility of accidents and injuries.
   (2) Safety will be given priority over expediency and shortcuts.
   (3) The company, it's managers, employees, and owner/operators will comply with all safety laws and regulations.
   (4) No passenger or ride-alongs are permitted while under dispatch.
Every manager, employee and owner/operator will be expected to demonstrate attitudes and actions which will reflect this policy for their own safety and for the safety of others. I understand and agree to the Safety Policy.

Accident Procedures

In the event you are involved in any accident on private property or public roads, you must call the company at 888-665-4904 option 6 and ask for Safety. They can be reached at this number 24/7. It is imperative that they are contacted at the scene of the accident to guide you through the proper steps to insure safety of all parties and lessen the liability for you, and the company. Enclosed is a complete accident procedure, accident report, and witness cards. In case accident requires you to be drug and alcohol tested, enclosed are instructions for the collection site, a chain of custody, mailing label, and an airborne express lab pack. Please keep this in your truck at all times. If you use or lose this packet, please ask your terminal manager for another.
CALL IMMEDIATELY FROM THE SCENE--888-665-4904 option 6
DRIVER MUST ALWAYS PERFORM A POST ACCIDENT AND DRUG AND BREATH ALCOHOL TEST WITHIN TWO HOURS OF THE ACCIDENT.

No Hazmat Policy

This is to certify that I understand and acknowledge that while I am leased to Genesis Worldwide LLC, I will, under no circumstances, transport any HAZARDOUS MATERIALS.

Your Tractor Must Be Properly Registered For "IRP" To Enter Each State

It is your responsibility to make sure all permits, licenses, and authorities are properly displayed, maintained, and not expired. If you are dispatched into any other state, call immediately for instructions, temporary permits may be needed. You are responsible to make sure you are legally permitted at all times.

One License Rule

ALL DRIVERS: PLEASE READ THE FOLLOWING STATEMENT. IF IT IS CORRECT AS IT APPLIES TO YOU, PLEASE CHECK

Verified Statement

I certify, under penalty of the laws of the United States Of America, that I do not hold any driver's license other than the one from my state of domicile. Further, I certify that I know that any false, fictitious or fraudulent statement of representation may be punishable under 18 U.S.C. 1901, which provides for fines up to $10,000.00, imprisonment up to 5 years, or both.

Notification Of License Suspension, Revocation, or Cancellation:

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 within 30 days to: 1) your employing motor carrier, and 2) the state that issued your license (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing.

Previous Pre-employment Employee Alcohol And Drug Test Statement

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Sec. 40.25(j) As the employer, you must also ask the the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process (see paragraphs (b)(5) and (e) of this section.

The prospective employee is required by Sec. 40.25(j) to respond to the following questions:

I HAVE TESTED POSITIVE, or REFUSED TO TEST, on any pre-employment drug or alcohol test administered by an employer to which I applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years

If you HAVE TESTED POSITIVE, you CAN PROVIDE/OBTAIN PROOF that you have SUCCESSFULLY COMPLETED the DOT return to duty requirements

Background Releases

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Request For Driver Safety Performance History Information From DOT Regulated Previous Employer(s)

As a Commercial Motor Vehicle (CMV) Driver, I understand that per the Federal Motor Carrier Safety Regulations (FMCSRs) Part 391.21, the following information will be requested from all previous employers for which I operated a CMV, subject to the FMCSR Parts 390 and/or 40, 382 & 383, within the past three years, from date shown below. I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part 391.23.
I hereby authorize this company to release all records of employment, including assessments of my job performance, ability and fitness, including dates of any and all alcohol or drug tests. Those confirmed results and/or my refusal to submit to any alcohol or drug tests and any rehabilitation completion under direction of (SAP/MRG) to each and every company (or their authorized agents) which may request such information in connection with my application for employment with said company. I hereby release this company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company.

General Consent For Limited Queries Of The Federal Motor Carrier Safety Administration (FMCSA) Drug And Alcohol Clearinghouse

I hereby provide consent to Genesis Worldwide LLC 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. I understand that if the limited query conducted by Genesis Worldwide LLC indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Genesis Worldwide LLC without first obtaining additonal specific consent from me. I further understand that if I refuse to provide consent for Genesis Worldwide LLC to conduct a limited query of the Clearinghouse, Genesis Worldwide LLC must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations

Combined Disclosure Notice And Authorization Regarding Background Consumer Reports

The Fair Credit Reporting Act requires that we inform you that a background investigation may be conducted as part of our screening and hiring process. This may include an inquiry to obtain information regarding your character, employment history, general reputation, personal characteristics, police record, education, qualifications, motor vehicle record, mode of living and/or credit and indebtedness. The primary objective of any investigation will be to verify information you provided on your application or during the interview process in connection with your application for and/or continued employment (or contract) with the company. A consumer report and/or an investigative consumer report may be obtained at any time during the application process or during your employment with the company. Upon timely written request to our personnel department, and within 5 days of the request, the name, address and phone number of the reporting agency and the nature and scope of the report (if one is made) will be provided to you. You have the right to request details of the report from the consumer reporting agency. Before any adverse action is taken, based in whole or in part on the information contained in the consumer report, you will be provided a copy of the report, the name, address and telephone number of the reporting agency, a summary of your rights under the Fair Credit Reporting Act, as well as an additional information on your rights under the law. The items of information requested below are required to process your background investigation. They are intended solely for that purpose and will not be used in a discriminatory manner for the making of business decisions. (A Copy of 'A Summary Of Your Rights Under The Fair Credit Reporting Act' is included with this authorization)

MN/CA/OK Residents Only - I wish to receive a copy of my consumer report

Disclosure And Authorization

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

In connection with your application for employment with Genesis Worldwide LLC ("Prospective Employer"), Prospective Employer, its employees, agent 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 my mail, telephone, computer, or other similar means, if the Prospective Employer used 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 on 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 Genesis Worldwide LLC ("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 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 Discloser 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.

Accident Procedures

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In the event you are involved in any accident on private property or public roads you must call Genesis Worldwide LLC Corporate office at 888-665-4904 (option 6) and ask for Todd Hammerstrom. This number should be called 24/7 to report ALL accidents. It is imperative that Genesis Worldwide LLC Office is contacted while the driver is at the scene of the accident to guide the driver through the proper steps to insure safety of all parties and lessen the liability for the Driver, and the Company. Enclosed in your accident pack is a complete accident procedure, accident report, and witness cards. In case accident requires you to be drug and alcohol tested, enclosed are instructions for the collection site, a chain of custody, mailing label and express lab pack. Please keep this in your truck at all times. If you use or lose this packet, please ask your terminal manager for another.

CALL IMMEDIATELY FROM THE SCENE
888-665-4904 (option 6)
ASK FOR TODD HAMMERSTROM

DRIVER MUST ALWAYS PERFORM A POST ACCIDENT DRUG AND BREATH ALCOHOL TEST WITHIN TWO HOURS OF THE ACCIDENT WHEN AN ACCIDENT IS DOT REPORTABLE...TODD HAMMERSTROM WILL INSTRUCT THE DRIVER REGARDING TESTING!

I have read and understand the Company's Accident Policy

Driver Legal Plan

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Driver Only: $2.98/weekly

Driver And Non-CDL Spouse: $4.48/weekly

Decline

I hereby apply to participate in DRIVERS LEGAL PLAN and AUTHORIZE you to deduct from my earnings the necessary plan fee as set forth above to be paid to DRIVERS LEGAL PLAN or its designate. I hereby authorize Drivers Legal Plan to employ any attorney to represent me, and sign my name, with my full authority and discretion to resolve any matter in connection with any and all traffic tickets and/or DataQ challenges I may have. In order to fulfill my obligation under the Federal Motor Carrier Safety Regulations §383.31 and my employer/lessor's safety policy, I hereby authorize Drivers Legal Plan to communicate with my employer/lessor regarding my case. I also understand that if I am no longer employed by or leased to this participating company or lessor, my participation will be cancelled. This authority is to remain in effect until revoked by me in writing.

Non-CDL Spouse Information

Name Phone Social Security # Birth Date Work Phone

Address City State Zip

Driver License # Issuing State

Documents

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Please attach a copy of the following documents:

Signature

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Please use mouse or touch pad to sign below

7 Day Previous Log

Motor carriers using a driver for the first time or intermittently shall obtain from the driver a signed statement giving the total time on duty during the immediately preceeding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(r) Federal Motor Carrier Safety Regulations

Day 1 Date Hours

Day 2 Date Hours

Day 3 Date Hours

Day 4 Date Hours

Day 5 Date Hours

Day 6 Date Hours

Day 7 Date Hours

I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at

Date Time

Check to electronically sign Date Signed

Probation - Hours Of Service - 6 Months