Name
Social Security #
Date of birth
Email
Can you provide proof of age? (Required for truck drivers) Yes No
Address
City
State/Country
Zip
Home phone
Cell phone
Driver's license number
Driver's license state
Driver's license type
Years OTR experience?
Tickets in past 3 years? (Details if applicable)	Yes No
Accidents in past 3 years? (Details if applicable)	Yes No
Have you worked for FTC Transportation, Inc. before?	Yes No
If so, when?
Are you a U.S. citizen?	Yes No
If not, do you have a legal right to work in the United States?	Yes No
Have you ever tested positive or refused to test on any pre-employment Drug or Alcohol test administered by an employer to which you applied for, but did not obtain employment during the past two years? Yes No
Employment History
Most Recent Employer
Name
Employer phone number
Address
Position held
From
To
Were you subject to FMSCR's?	Yes No
Was Job Designated as a Safety Sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR Part 40? Yes No
Are you presently employed?	Yes No
May we contact your current employer?	Yes No
Why do you want to change employers?
Second-to-last Employer
Name
Employer phone number
Address
Position held
From
To
Reason for leaving?
Were you subject to FMSCR's?	Yes No
Was Job Designated as a Safety Sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR Part 40? Yes No
Third-to-last Employer
Name
Employer phone number
Address
Position held
From
To
Reason for leaving?
Were you subject to FMSCR's?	Yes No
Was Job Designated as a Safety Sensitive function in any DOT regulated mode subject to drug and alcohol testing as required by 49 CFR Part 40? Yes No

DISCLOSURE AND RELEASE
In connection with my application for employment (including contract for services) with FTC Transportation, Inc., I understand that a consumer report, which may contain public record information, is being requested from DAC Services, Tulsa, Oklahoma. This report may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc.. I further understand that such reports may contain public record information concerning my driving record, worker’s compensation claims, credit, bankruptcy proceedings, criminal records, etc. from federal, state, and other agencies which maintain such records, as well as information from DAC Services concerning previous driving records requests made by other such state agencies and state provided driving records.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTRACTED BY DAC SERVICES TO FURNISH THE ABOVE-MENTIONED INFORMATION
I hereby certify that all information on this form is correct and complete to the best of my knowledge. I hereby authorize FTC Transportation, Inc., to do a complete background investigation in accordance with state and federal laws. I authorize release of any information, including all information related to my alcohol and controlled substances testing and training records required by the Federal Highway Administration (FHWA) 49 CFR Parts 391 and 382, by any past or current employers. I hereby release all such persons from any liability or damages. I consent to the procurement and use of any consumer reports, including reports from DAC/USIS Services, Inc., deemed necessary by FTC Transportation, Inc. or its subsidiaries in their consideration of my employment.

I understand that I have the right to review information provided by previous employers, have errors corrected by previous employer and resubmitted to FTC Transportation, Inc. and/or have a rebuttal statement attached to the erroneous information if my previous employer and I cannot agree on the accuracy of the information. I understand that I must request past employer information obtained by FTC Transportation, Inc. in writing within 30-days of my application.

Accept

Do not accept

Signed

Date

Thank you!
Please review the information above for any corrections, then press the 'SUBMIT' button.