Owner/Operator Application
 
Driver Information Sheet

Please complete all information: 
Date: 2/9/2010
 
    Personal Information
Name 
  Last 
Last Name is required.		 First 
First Name is required.		 Middle
Address 
Address is required.		 Phone Number   ()-
Please enter the numeric phone number with the area code.
City     State     Zip     How long (months)? 
City is required. State is required. A valid zip is required. Number of months is invalid.
Age  Social Security Number  --
Please enter the numeric SSN.
Date of Birth    MM/DD/YYYY
Please enter your birth date in mm/dd/yyyy format.		 Email Address 
Please enter a valid email address.
  Addresses You Resided in the Last Three (3) Years
Address 
Address is required.
City 
City is required.
State   Zip 
State is required. Zip is invalid.
How long (months)? 
Please enter how many months at this address.
     
All addresses must be entered in the below list.
Address How long
 
  Emergency Notification Contact Information
 
Name 
Address 
City 
State   Zip
Zip is invalid.
Phone 
()-
Please enter the numeric phone number with the area code.
 
    Other Information
 
How did you hear about us?
Please choose a value.
Driver Type
Job Type
Trailer Type
Do you own a tractor?
Yes No
Do you have 1 year of tractor trailer experience in the last 3 years?
Yes No
Has your license been suspended in the last 10 years?
Yes No
Have you been convicted of a DUI/DWI in the last 10 years?
Yes No
 
 
    Contract / Employment Record
 
Complete the information for each employer/contract for the last ten (10) years with no gaps in employment.
 
Period of Unemployment?
Yes No
From  
Please enter a valid date.		 To  
Please enter a valid date.
The To date must be after the From date.
Last Contract/Employer      Supervisor 
Employer is required.
Address        City  
Address is required. City is required.
State  
State is required. 		Zip  
Invalid Zip Code.
Phone  
()-
Please enter the numeric phone number with the area code.
Position Held     
Salary        Type  
Salary must be numeric.
Describe Your Work
Reason for Leaving
At this contract/employer, were you subject to Federal Motor Carrier Safety Regulations?
Yes No
At this contract/employer, was your position designated as a safety-sensitive function in any DOT regulation and subject to alcohol and controlled substance testing required by 49 CFR, Part 40?
Yes No
 
All previous employment entries must be entered in the below list.
 
Employer Phone Address Position From To Salary Type
 
 
    Education
 
Highest Grade Completed High School College
Last School Attended
 
 
    Driver License Record
 
List all licenses you have held in the last three (3) years.
 
Type 
Please select Class.		   Issuing State 
Please select state.		   Number 
Number is required.		   Exp Date  
Please enter a valid date.
 


All licenses must be entered in the below list.
 
Type Issuing State License Number Exp. Date
 
Has any license, permit, or privilege to operate a motor vehicle that has been issued to you ever been denied, revoked or suspended?
Yes No
If your answer is yes, explain the facts and circumstances involving such action.
 
 
    Previous Driving Experience
 
Have you been leased as a driver or owner/operator by any other motor carriers prior to the date of this information sheet?
Yes No
If so, how long (years) did you operate: Straight Trucks     Tractor Trailer Combinations 
Value must be numeric. Value must be numeric.
As a driver or owner/operator, have you driven semi's pulling box or reefer type trailers?
Yes No
In what part of the country have you driven? (Indicate number of years for each part of the country.)
West Coast   Pacific N. West   Rocky Mtns   Midwest  
Invalid value. Invalid value. Invalid value. Invalid value.
Southwest   Southeast   Northeast  
Invalid value. Invalid value. Invalid value.
 
 
    Accident Record
 
List all accidents in which you were involved as a driver during the preceding three (3) years. None


Date  
Please enter a valid date.
   Location 
Nature   No. of Fatalities   No. of Injuries 
Value must be numeric. Value must be numeric.
 

All accidents must be entered in the below list.
 
Date Location Accident Nature No. of fatalities No. of injuries
 
 
    Traffic Violation Record
 
 
List all violations of motor vehicle law or ordinances (other than parking) of which you were convicted or forfeited bond or collateral during the preceding three (3) years. None


Date  
Please enter a valid date.		 Type   Location  
 
All violations must be entered in the below list.
 
Date Type Location
 
 
    Substance Abuse Information
 
 
In the last three years, have you tested positive, or refused to test, on any pre-employment drug or alcohol test administrated by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules?
Yes No

 
 
By clicking the Agree & Submit button, I certify that I have read, understand and agree to comply with Paramount Freight Systems LLC Statement of Policy on Drug Abuse. By entering into a lease with Paramount Freight Systems LLC, I also consent to submit to urine testing for drugs and controlled substances and I agree to comply with all of the requirements of Paramount Freight Systems LLC, the Federal Motor Carrier Safety Regulations and any federal, state or local laws and rules governing the use of drugs and controlled substances. I understand that my failure to honor the terms of this agreement will be grounds for termination of my lease, or loss of consideration of my application for lease with Paramount Freight Systems LLC.

Furthermore, I certify that I completed the information in this electronic form and that all entries and information in it are true and complete to the best of my knowledge. I authorize Paramount Freight Systems LLC to make such investigations and inquiries of my personal, employment, state motor vehicle record, financial history, medical history, and other related matters as may be necessary in arriving at a leasing decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of leasing has been extended.) I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my answers. In the event of leasing, I understand that false or misleading information given in my answers or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company.

I hereby release prior employers/contractees and the individual supplying the applicable information from any and all liability resulting from the release of any information regarding my safety performance history as required by 49 CFR 391.23(d) and (e) and I understand the rights provided for in 49 CFR 391.23(i).

In accordance with FMCSR 391.21(d), as an applicant, I understand I am afforded the following rights regarding investigative information that will be requested and provided by my previous employer(s). These rights are stated below and by electronically submitting this document I confirm receipt and understanding of these rights per 391.23(i). 

(i)(1)(i) The right to review information provided by previous employers

(i)(1)(ii) The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective motor carrier;

(i)(1)(iii) 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.

(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective motor carrier, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of qualification. The prospective motor carrier must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective motor carrier has not yet received the requested information from the previous employer(s), then the five-business day's deadline will begin when the prospective motor carrier receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective motor carrier making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

I have read and agree to the terms stated in this agreement.
 
 
© 2008 Paramount Freight Systems LLC