UPLOAD A PICTURE OF YOUR CDL PLEASE.* In compliance with Federal a State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability. PLEASE COMPLETE AND SUBMIT THIS APPLICATION WITH AS MUCH INFORMATION AS POSSIBLE, ANY INCOMPLETE DATA MIGHT DELAY THE PROCESS. IF YOU HAVE ANY QUESTIONS OR PREFER TO COMPLETE THIS APPLICATION IN PERSON, PLEASE CONTACT US AND WE WILL BE HAPPY TO GUIDE YOU. WE LOOK FORWARD TO HEARING FROM YOU. DMK EXPRESS INC 6601 South Menard Ave Bedford Park IL, 60638 PHONE: 708-546-0508 FAX: 708-546-0758 HOW MUCH TRUCK DRIVING EXPERIENCE DO YOU HAVE? —Please choose an option—0-3 Months4-6 Months7-12Months1-2 Years3-4 Years5 Years+ DO YOU HAVE ANY EXPERIENCE WITH INTERMODAL / RAIL YARDS? —Please choose an option—0-3 Months4-6 Months7-12Months1-2 Years3-4 Years5 Years+ HOW DID YOU HEAR ABOUT US? —Please choose an option—FacebookWebsiteWord of mouthGoogleCurrent employeeOther Date Your name Last name Date of Birth Your Phone Number Your email Your adress HOW LONG AT CURRENT ADDRESS? —Please choose an option—< 1 year1 to 3 years3+ years DO YOU HAVE A LEGAL RIGHT TO WORK IN THE UNITED STATES? —Please choose an option—YesNo SOCIAL SECURITY NUMBER HAVE YOU WORKED FOR DMK BEFORE? —Please choose an option—YesNo IF YES, WHAT DATE DID YOU LAST WORK AT DMK? WHAT WAS YOUR POSITION AT DMK? WHAT WERE YOUR REASONS FOR LEAVING? ARE YOU CURRENTLY EMPLOYED? —Please choose an option—YesNo IF NOT CURRENTLY EMPLOYED, HOW LONG SINCE LAST EMPLOYMENT? BACKGROUND INQUIRY AUTHORIZATION I authorize DMK to obtain any and all past employment records regarding previous employment and other areas of my background such as past employer inquiries, retail credit inquiries, criminal records inquiries, driving history, educational records and drug testing results: I agree to hold DMK and its clients harmless regarding any information that is obtained during the background inquiry. To all my previous employer and holders of public records: Please accept this faxed or mailed document as an original authorization for release of all employment records including reason for termination or resignation, criminal records, past drug and alcohol tests and transcripts of educational accomplishments. Applicant: The request for your date of birth is to be used in performing criminal records search only. The client in consideration of employment does not use it. CURRENT EMPLOYMENT EMPLOYER NAME: EMPLOYER ADDRESS: START DATE END DATE POSITION HELD REASONS FOR LEAVING WERE YOU SUBJECT TO THE FMCSR'S WHILE EMPLOYED? —Please choose an option—YesNo WAS YOUR JOB DESIGNATED AS A SAFETY -SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART? —Please choose an option—YesNo MINIMUM 3 YEARS OF EMPLOYMENT HISTORY IS REQUIRED, IF ADDITIONAL SPACE IS NEEDED PLEASE COMPLETE ON SEPERATE SHEET AND ATTACH BELOW. ADDITIONAL EMPLOYMENT HISTORY IS THERE ANY REASON YOU MIGHT BE UNABLE TO PERFORM THE FUNCTIONS OF THE JOB FOR WHICH YOU ARE APPLYING? —Please choose an option—YesNo IF YES, PLEASE EXPLAIN. ANY ACCIDENTS IN THE PAST 3 YEARS? —Please choose an option—YesNo DO YOU HAVE ANY TRAFFIC CONVICTIONS AND FORFEITURES IN THE LAST 3 YEARS? (DO NOT NEED TO INCLUDE PARKING VIOLATIONS)? —Please choose an option—YesNo HAVE YOU EVER HAD YOUR LICENSE , PERMIT OR PRIVILEGE SUSPENDED, REVOKED OR DENIED? —Please choose an option—YesNo IF "YES" PLEASE EXPLAIN. LIST THE TYPE OF EQUIPMENT YOU HAVE DRIVEN AND AMOUNT OF TIME. LIST ANY STATES IN WHICH YOU HAVE OPERATED IN THE LAST 5 YEARS. LIST ANY SPECIAL COURSES TAKEN WHICH HELP YOU IN YOUR JOB AS A DRIVER. EDUCATION HIGHEST EDUCATION LEVEL COMPLETED —Please choose an option—NONEK-8HIGH SCHOOL DIPLOMAGEDSOME COLLEGECOLLEGE DEGREE LAST SCHOOL ATTENDED ANYTHING ELSE YOU WOULD LIKE US TO KNOW THAT WAS NOT INCLUDED ABOVE? FORMER EMPLOYEE INFORMATION AND RELEASE I hereby authorize to release the following requested information to DMK EXPRESS, INC. for the purpose of investigation and qualifying me to drive a commercial motor vehicle as required by the U.S. Department of Transportation and Federal Motor Carrier Safety Regulations Parts 382, 391, 392 and 49 CFR Part 40. You are hereby released from any and all liability that may result from furnishing such information. Your quick response to this request will be greatly appreciated. Motor Vehicles Driver’s CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS 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. POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator’s license. If you have more than one license, 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, close your record by notifying the state of issuance that you no longer want to be licensed by that state. 2. 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 to your employing motor carrier, and the state that issued your license within 30 days. I certify The following license is the only one I will possess: IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with DMK EXPRESS INC (“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 f you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize DMK EXPRESS INC (“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. 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 General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse I hereby provide consent to DMK EXPRESS INC. to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists on the Clearinghouse. I understand that if the limited query conducted by DMK EXPRESS INC. indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to DMK EXPRESS INC. without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for DMK EXPRESS INC. to conduct a limited query of the Clearinghouse, DMK EXPRESS INC. must prohibit me from performing safety-sensitive functions, including a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations. TO BE READ AND SIGNED BY APPLICANT 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. Today's Date Your Signature* Add a digital signature using your mouse, stylus, or finger.
