Driver Application Form

Personal Information

First Name*

Middle Initial

Last Name*

Current Address*

City*

State*

Zip Code*

Social Security Number*

Date of Birth*

Country*

Primary Phone*

Email Address*

Yes, I agree to receive information concerning future opportunities or promotions from JB Harris Transport LLC by email or other commercial electronic communications.

Yes

No

Would you like to receive communication from JB Harris Transport LLC via text message?

By participating, you consent to receive text messages sent by an automatic telephone dialing system. You may opt out at any time by texting STOP.

Yes

No

Residence at current address 3 years or longer?*

Yes

No

If No, provide previous addresses for last 3 years:

Position Information

Position Applying For*

Preferred Location*

Are you legally eligible for employment in the United States?*

Yes

No

Are you currently employed?

Yes

No

Company Questions - General Information

If you answered "Owner Operator" or "Fleet Owner", select yes:

Yes

No

What date did your last employment end?

Do you read, write, and speak English?*

Yes

No

Have you ever worked for this company before?*

Yes

No

Have you ever been known by any other name?*

Yes

No

Enter name:

How did you hear about us?*

If "Driver Referral", please enter the driver's name:

If "Other", please explain:

License Information

License Number*

License State*

License Class*

License Expiration Date*

DOT Medical Card Expiration*

Endorsements

Tanker

HAZMAT

X Endorsement

Doubles/Triples

Do you have a current TWIC card?

Yes

No

TWIC Expiration Date (if applicable)

Driving Experience

Straight Truck Experience

Tractor and Semi-Trailer Experience*

Tractor - Two Trailers Experience

Employment History (Last 7 Years)

Please provide all employment/unemployment for the past 7 years

How many employers/periods have you had in the last 7 years?*

FMCSR Compliance Questions

Under FMCSR 391.15, are you currently disqualified from driving a commercial motor vehicle? [49 CFR 391.15]*

Yes

No

Has your license, permit or privilege to drive ever been suspended or revoked for any reason? [49 CFR 391.21(b)(9)]*

Yes

No

Have you ever been denied a license, permit, or privilege to operate a motor vehicle? [49 CFR 391.21(b)(9)]*

Yes

No

Within the past two years, have you tested positive, or refused to test, on a pre-employment drug or alcohol test by an employer to whom you applied, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules? [49 CFR 40.25(j)]*

Yes

No

In the past three (3) years, have you ever been convicted of any of the following offenses: [49 CFR 391.15]*

Driving a commercial motor vehicle with a blood alcohol concentration ("BAC") of .04 percent or more
Driving under the influence of alcohol, as prescribed by state law
Refusal to undergo drug and alcohol testing as required by any jurisdiction for the enforcement of Federal Motor Carrier Safety Act regulations
Driving a commercial motor vehicle under the influence of any 21 C.F.R. 1308.11 Schedule I identified controlled substance, an amphetamine, a narcotic drug, a formulation of an amphetamine, or a derivative of a narcotic drug
Transportation, possession, or unlawful use of a 21 C.F.R. 1308.11 Schedule I identified controlled substance, amphetamines, narcotic drugs, formulations of an amphetamine, or derivatives of narcotic drugs while you were on duty driving for a motor carrier
Leaving the scene of an accident while operating a commercial motor vehicle
Or any other felony involving the use of a commercial motor vehicle

Yes

No

Vehicle Accident Record

Were you involved in any accidents/incidents with any vehicle in the last 5 years (even if not at fault)?*

Yes

No (No Accidents)

Traffic Convictions / Violations

Have you had any moving violations or traffic convictions in the past 3 years?*

Yes

No (No Violations)

Signature

Certification: 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. By signing my application below, I agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.*

Full Name (Electronic Signature)*

Date*

Federal FCRA Summary of Rights & Authorizations

Federal FCRA Summary of Rights Acknowledgment: By checking this box, I (a) acknowledge that I have read and understand the federal FCRA Summary of Rights and have been given the opportunity to copy/print the Summary of Rights and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.*

PSP Disclosure and Authorization: By checking the box, I (a) acknowledge that I have read and understand the PSP Disclosure and Authorization and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.*

FCRA Disclosure: By checking the box, I (a) acknowledge that I have read and understand the above and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.*

FCRA Authorization: By checking the box, I (a) acknowledge that I have read and understand the above and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.*

Employment Verification Acknowledgment and Release (DOT Drug and Alcohol): By checking the box, I (a) acknowledge that I have read and understand the above and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.*

Clearinghouse Release: By checking the box, I (a) acknowledge that I have read and understand the above and also have been given the opportunity to copy/print it, and (b) agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature.*

1681m: By checking this box, I represent that I understand and agree to the above document.*

INVESTIGATIVE CONSUMER REPORT DISCLOSURE: By checking this box, I represent that I understand and agree to the above document.*