Application

America's

Service

Line, LLC

1814 Elizabeth Street
Green Bay, WI 54302
Phone: (800) 996-6440
Fax: (920) 430-8433
Recruiting

Application For Qualification

The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to Federal Motor Carrier Safety Regulations and America's Service Line, LLC

Please answer all of the questions.
If the answer is "no" or "none", do not leave it blank, write "no" or "none" in the space provided.
The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40, but less than 70 years of age.

Incomplete or unreadable applications will not be processed.

Name:

Address:

City:

State:

Zipcode:

Phone:

Cell:

License #:

License State:

Expiration:

Age:

Date of Birth:

Physical Expiration Date:

Emergency Contact Information:

Name:

Phone:

Previous Street Address 1:

Previous City 1:

Previous State 1:

Previous Zipcode 1:

Previous Street Address 2:

Previous City 2:

Previous State 2:

Previous Zipcode 2:

Previous Street Address 3:

Previous City 3:

Previous State 3:

Previous Zipcode 3:

Have you ever been denied a license, permit, or privilage to operate a motor vehicle?

Yes

Has any license permit or privilage ever been suspended or revoked?

Yes

Have you ever tested positive or refused a D.O.T. drug and or alcohol test of any kind or alcohol pre employment test within the past two years from an employer who did not hire you?

Yes

Have you ever been convicted of a felony?

Yes

If you answered "yes" to any of the above, give details:

EMPLOYMENT HISTORY

Give a COMPLETE RECORD of all employment for the past three years, including all full-time and part-time employment. Then list only commercial driving positions held for a total period of ten years. ALL TIME FOR THE PAST THREE YEARS MUST BE ACCOUNTED FOR including periods of unemployment. WE MUST HAVE PHONE NUMBERS. Start with your present or most recent position and work backwards.

Are you currently employed?

Yes

If yes, may we contact your present employer?

Yes

Employment History 1:

Name:

Start Date:

End Date:

Address:

City:

State:

Zipcode:

Phone:

Position Held:

Reason for Leaving:

IF YOU DROVE A COMMERCIAL MOTOR VEHICLE, PLEASE ANSWER THE FOLLOWING QUESTIONS

Type of Cargo Hauled:

Area of Operation:

If your employer had you qualified to drive for a motor carrier other than your employer, please give name and address of that carrier:

No. of accidents or incidents:

Explain Each:

Employment History 2:

Name:

Start Date:

End Date:

Address:

City:

State:

Zipcode:

Phone:

Position Held:

Reason for Leaving:

IF YOU DROVE A COMMERCIAL MOTOR VEHICLE, PLEASE ANSWER THE FOLLOWING QUESTIONS

Type of Cargo Hauled:

Area of Operation:

If your employer had you qualified to drive for a motor carrier other than your employer, please give name and address of that carrier:

No. of accidents or incidents:

Explain Each:

Employment History 3:

Name:

Start Date:

End Date:

Address:

City:

State:

Zipcode:

Phone:

Position Held:

Reason for Leaving:

IF YOU DROVE A COMMERCIAL MOTOR VEHICLE, PLEASE ANSWER THE FOLLOWING QUESTIONS

Type of Cargo Hauled:

Area of Operation:

If your employer had you qualified to drive for a motor carrier other than your employer, please give name and address of that carrier:

No. of accidents or incidents:

Explain Each:

DRIVING EXPERIENCE

Straight Truck

Years Experience:

Approximate No. of Miles:

Tractor and Semi Trailer

Years Experience:

Approximate No. of Miles:

Accident in the past three years (attach sheet if needed)

Date:	Type:	Location:

# Injuries:	# Fatalities:

Date:	Type:	Location:

# Injuries:	# Fatalities:

Date:	Type:	Location:

# Injuries:	# Fatalities:

Traffic convictions, moving violations for the past three (3) years
(other than parking violations)

Date:	Location:	Charge:

Penalty:

Date:	Location:	Charge:

Penalty:

Date:	Location:	Charge:

Penalty:

Drivers license
(List each driver's license held in the past three years. Attach additional sheet if necessary)

State:		License #:

Type:		Endorsements:

Expiration Date:

State:		License #:

Type:		Endorsements:

Expiration Date:

TO BE READ BY APPLICANT

I certify that I have read and understood all of this employment application. It is agreed and understood that the employer or his agents may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons named herin from any and all liability for any and all damages on account of furnishing such information. I understand that, as an appplicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the results of a physical examination and drug test.

I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I understand that I have a right to review the information obtained from previous employers, to correct errors in that information, and rebut preceived incorrect information.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of the employer.

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.

Signature of applicant: (to be collected by America's Service Line)

RECORDS RELEASE

I, (name), -- Social Security Number (collected by America's Service Line LLC.),to release all records of employment, including assessments of my job performance, ability, and fitness information, to America’s Service Line, LLC for purposes of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information.

In connection with my application for employment (including contract for services) with you, I understand that a consumer report, which may contain public record information, is being requested from DAC Services, Tulsa, Oklahoma.

In accordance with 49 CFR 382.405(f) and 382.413(b), you are hereby authorized and requested to furnish any and all information in your possession concerning my participation in a drug and alcohol testing program under 49 CFR Part 382. I specifically authorize you to release information on any alcohol tests and or refusals to be tested within three years preceding the date of this request. I further authorize and request you to release any information in your possession concerning my evaluation in any treatment or rehab recommended by the substance abuse profession and the results of any return to duty drug or alcohol test within three years preceding this requests.

I hereby release this company; its employees, officers, directors, and agents from any and all liability of any type as a result of providing the above information to America's Service Line LLC.

Signature: ________________________ Date:

CONFIDENTIAL REPORT OF ALCOHOL/CONTROLLED SUBSTANCE TESTING

Please furnish the following information pursuant to 49 CFR section 382.405(f) regarding:
Name:
Social Security Number: (collected by America's Service Line LLC.)
I hearby authorize and request to release information concerning any and all violations of prohibitions of 382.413(a)(1) which you have knowledge of, occurring within the previous three (3) years, to America’s Service Line, LLC

Signed: Date:

Information from Section 382.413(a)(1) & (2):

1.	Has the above named individual had an alcohol test with breath concentration of 1.04 or greater in the past three (3) years? YES NO
	If yes, date:

2.	Has the above named individual had a controlled substance test with a positive result in the past three (3) years? YES NO
	If yes, date:

3.	Has the above named individual refused a controlled substance test or alcohol test within the past three (3) years? YES NO

4.	Has the above named individual ever violated other provision of DOT testing to your knowledge? YES NO
	If yes, date:

5.	Have you received information from a previous employer that the above named individual violated DOT drug and alcohol regulations in the past three years or beyond? YES NO
	If yes, date:

If any of the above questions were answered "YES", please provide the Substance Abuse Professional (SAP) information:

Name:

Address:

Telephone

Date of Referral

Signeture:

Title:

Date:

Failure to furnish information as requested by 49 CFR 382.41(b) within 14 days is a violation of 49 CFR 382.405(f). Failure to furnish the above information will result in documentation of such failure to comply. This documentation will be made available to any DOT agency with regulatory authority requesting it.

If applying for a company driving position, you must also fill out the American Foods Group application. Click SEND on both forms.