Wayne Smith Trucking Inc.

Morrilton, Arkansas

Driver's Application For Employment

All fields are required. Please fill out the appropriate fields highlighted in red, then continue.

In compliance with Federal and State Equal 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.

All fields are required.

Date
Social Security Number
Last Name
First Name
Middle Name

Current Address

(list previous 3 years)

Address 1
City 1
State 1
Zip Code 1
How Long?
Address 2
City 2
State 2
Zip Code 2
How Long?
Address 3
City 3
State 3
Zip Code 3
How Long?

Phone Numbers:

Home Phone
Mobile Phone

Emergency Contact:

Name
Relationship
Phone

Date of Birth:

Month
Day
Year
Do you have the legal right to work in the United States?
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Have you worked for Wayne Smith Trucking Inc. before?
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If yes, when to when?
Reason for leaving?
Are you employed now?
If not, how long since you've last been employed?
Referred by:
Position you are applying for:

Education

All fields are required. Please fill out the appropriate fields highlighted in red, then continue.

Last school attended
City (School Attended)
Years Completed (High School)
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Years Completed (College)
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Driving Related School
Date Completed (Driving School 1)
Driving Related School
Date Completed (Driving School 2)
Driving Related School
Date Completed (Driving School 3)

Employment History

All fields are required. Please fill out the appropriate fields highlighted in red, then continue.

Employer 1

Name (Employer 1)
Address (Employer 1)
City (Employer 1)
State (Employer 1)
Zip (Employer 1)
Phone (Employer 1)
Contact (Employer 1)
From (Employer 1)
To (Employer 1)
Wage (Employer 1)
Reason for Leaving (Employer 1)
Position (Employer 1)

Employer 2

Name (Employer 2)
Address (Employer 2)
City (Employer 2)
State (Employer 2)
Zip (Employer 2)
Phone (Employer 2)
Contact (Employer 2)
From (Employer 2)
To (Employer 2)
Wage (Employer 2)
Reason for Leaving (Employer 2)
Position (Employer 2)

Employer 3

Name (Employer 3)
Address (Employer 3)
City (Employer 3)
State (Employer 3)
Zip (Employer 3)
Phone (Employer 3)
Contact (Employer 3)
From (Employer 3)
To (Employer 3)
Wage (Employer 3)
Reason for Leaving (Employer 3)
Position (Employer 3)

Employer 4

Name (Employer 4)
Address (Employer 4)
City (Employer 4)
State (Employer 4)
Zip (Employer 4)
Phone (Employer 4)
Contact (Employer 4)
From (Employer 4)
To (Employer 4)
Wage (Employer 4)
Reason for Leaving (Employer 4)
Position (Employer 4)

Employer 5

Name (Employer 5)
Address (Employer 5)
City (Employer 5)
State (Employer 5)
Zip (Employer 5)
Phone (Employer 5)
Contact (Employer 5)
From (Employer 5)
To (Employer 5)
Wage (Employer 5)
Reason for Leaving (Employer 5)
Position (Employer 5)

Employer 6

Name (Employer 6)
Address (Employer 6)
City (Employer 6)
State (Employer 6)
Zip (Employer 6)
Phone (Employer 6)
Contact (Employer 6)
From (Employer 6)
To (Employer 6)
Wage (Employer 6)
Reason for Leaving (Employer 6)
Position (Employer 6)

Employer 7

Name (Employer 7)
Address (Employer 7)
City (Employer 7)
State (Employer 7)
Zip (Employer 7)
Phone (Employer 7)
Contact (Employer 7)
From (Employer 7)
To (Employer 7)
Wage (Employer 7)
Reason for Leaving (Employer 7)
Position (Employer 7)

Employer 8

Name (Employer 8)
Address (Employer 8)
City (Employer 8)
State (Employer 8)
Zip (Employer 8)
Phone (Employer 8)
Contact (Employer 8)
From (Employer 8)
To (Employer 8)
Wage (Employer 8)
Reason for Leaving (Employer 8)
Position (Employer 8)

Employer 9

Name (Employer 9)
Address (Employer 9)
City (Employer 9)
State (Employer 9)
Zip (Employer 9)
Phone (Employer 9)
Contact (Employer 9)
From (Employer 9)
To (Employer 9)
Wage (Employer 9)
Reason for Leaving (Employer 9)
Position (Employer 9)

Employer 10

Name (Employer 10)
Address (Employer 10)
City (Employer 10)
State (Employer 10)
Zip (Employer 10)
Phone (Employer 10)
Contact (Employer 10)
From (Employer 10)
To (Employer 10)
Wage (Employer 10)
Reason for Leaving (Employer 10)
Position (Employer 10)

Employer 11

Name (Employer 11)
Address (Employer 11)
City (Employer 11)
State (Employer 11)
Zip (Employer 11)
Phone (Employer 11)
Contact (Employer 11)
From (Employer 11)
To (Employer 11)
Wage (Employer 11)
Reason for Leaving (Employer 11)
Position (Employer 11)

Employer 12

Name (Employer 12)
Address (Employer 12)
City (Employer 12)
State (Employer 12)
Zip (Employer 12)
Phone (Employer 12)
Contact (Employer 12)
From (Employer 12)
To (Employer 12)
Wage (Employer 12)
Reason for Leaving (Employer 12)
Position (Employer 12)

Driving Record

All fields are required. Please fill out the appropriate fields highlighted in red, then continue.

Traffic Convictions

(if none, check this box) I have no traffic convictions
Location (Traffic Conviction 1)
Date (Traffic Conviction 1)
Charge (Traffic Conviction 1)
Penalty (Traffic Conviction 1)
Location (Traffic Conviction 2)
Date (Traffic Conviction 2)
Charge (Traffic Conviction 2)
Penalty (Traffic Conviction 2)
Location (Traffic Conviction 3)
Date (Traffic Conviction 3)
Charge (Traffic Conviction 3)
Penalty (Traffic Conviction 3)
Location (Traffic Conviction 4)
Date (Traffic Conviction 4)
Charge (Traffic Conviction 4)
Penalty (Traffic Conviction 4)

Accidents

(if none, check this box) I have no accidents
Location (Accident 1)
Date (Accident 1)
Charge (Accident 1)
Penalty (Accident 1)
Location (Accident 2)
Date (Accident 2)
Charge (Accident 2)
Penalty (Accident 2)
Location (Accident 3)
Date (Accident 3)
Charge (Accident 3)
Penalty (Accident 3)
Location (Accident 4)
Date (Accident 4)
Charge (Accident 4)
Penalty (Accident 4)

CDL Information

License Number
State (CDL)
Class
Endorsements
Expiration (CDL)
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
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Has any license, permit or privilege ever been suspended or revoked?
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If yes to either of the above questions, please explain:

Driving Experience

Equipment Type 1
Dates (Equipment Type 1)
To (Equipment Type 1)
Approximate Miles (Equipment Type 1)
Equipment Type 2
Dates (Equipment Type 2)
To (Equipment Type 2)
Approximate Miles (Equipment Type 2)
Equipment Type 3
Dates (Equipment Type 3)
To (Equipment Type 3)
Approximate Miles (Equipment Type 3)
Equipment Type 4
Dates (Equipment Type 4)
To (Equipment Type 4)
Approximate Miles (Equipment Type 4)
List Driving Related Awards or Recognitions
List other experience or skills that may help in your work for this company
Have you ever been convicted of a felony? If yes, please explain (a yes answer does not automatically disqualify you)

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

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPPORTS FROM THE PSP Online Service

All fields are required. Please fill out the appropriate fields highlighted in red, then continue.

In connection with your application for employment with Wayne Smith Trucking, 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

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Wayne Smith Trucking, 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 agree with this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby acknowledge that by typing in my name and clicking “I Agree” below, I authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

Date
Name
I Agree

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.

RELEASE OF RECORD FOR ALCOHOL AND DRUG TESTS RESULTS

All fields are required. Please fill out the appropriate fields highlighted in red, then continue.

I, do hereby authorize the Office of Driver Services to release my record of alcohol and drug tests results to:

Wayne Smith Trucking Inc.
41 WST Circle, Morrilton, AR 72110

By typing your name and checking "I Agree" below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement.

Signature
Date
Date of Birth
Drivers License Number
I Agree

This Consent is only valid for pre employment and employment purposes as required by Arkansas Code Annotated §27-23-207.

HireRight DAC Trucking

Trucking Industry: DOT D/A Disclosure and Authorization

All fields are required. Please fill out the appropriate fields highlighted in red, then continue.

PART I – DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYENT PURPOSES – 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT regulated drug and alcohol testing records by the DOT regulated employer(s) listed below to HireRight for the purpose of HireRight transmitting such records to the HireRight customer listed above. I understand that information/documents released pursuant to this Part I is limited to the following DOT regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation.

If any company listed below furnishes HireRight with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to HireRight, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years.

List all DOT regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature.

Previous DOT Regulated Employer
City
State
Phone Number
Previous DOT Regulated Employer
City
State
Phone Number
Previous DOT Regulated Employer
City
State
Phone Number
Previous DOT Regulated Employer
City
State
Phone Number
Previous DOT Regulated Employer
City
State
Phone Number
Previous DOT Regulated Employer
City
State
Phone Number

By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.

Print Applicant Name:
Social Security #:
Applicant Signature:
Date:
I Accept

Part 2 – FMCSA Notification of Driver Rights

All fields are required. Please fill out the appropriate fields highlighted in red, then continue.

In compliance with 49 CFR Part §40 391.23 you have certain rights regarding the safety 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 that 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 preceding 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, the prospective employers may consider you to have waived your request to review the second.

By typing your name and checking "I Agree" below, you agree that you read the notification of your rights as outlined in the paragraph above.

Date
Name
I Agree

All fields are required. Please fill out the appropriate fields highlighted in red, then continue.

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 herein from all liability for any damages on account of furnishing such information. I understand that, as an applicant 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 will 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 may include an investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

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 of 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.

By typing your name and checking "I Accept" below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document(hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Wayne Smith Trucking Inc. You are also confirming that you are the individual authorized to enter into this Agreement.

Date
Name
I Accept

I hereby authorize you to release all information concerning my employment including oral assessments of my job performance, ability, and fitness to Wayne Smith Trucking (or its designated agent) in connection with my application for employment with this company. I hereby release you from any and all liability of any type as a result of providing the above mentioned information to the above mentioned company.

By typing your name and checking "I Accept" below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement.

Applicant
Social Security Number
Signature
Date
I Accept