No application shall be accepted that is not complete. Please ensure that you are properly prepared to complete this application. This includes full names, addresses, zip codes, and telephone numbers where
indicated. Incomplete or unreadable applications will
This form must be completed by each FMCSA regulated employee. There will be no blank spaces, and all printed information must be neat and legible. This form will be used to update your U.S.DOT driver qualification file.
List the person(s) you wish contacted in the event of a medical emergency
List all allergies to medications, known medical conditions, daily medications, or known medic alert.
( ATTACH ADDITIONAL SHEET IF NEEDED )
List all Accidents - Commercial or Private - Regardless of Fault
No application shall be accepted that is not complete.
Please ensure that you are properly prepared to
complete this application. This includes full names,
addresses, zip codes, and telephone numbers where indicated. Incomplete or unreadable applications will be rejected.
NOTE: Our company complies with the Americans with Disabilities Act ( ADA ) and our company will consider making reasonable accommodations necessary for eligible applicants / employees to perform essential functions. The hiring of such an applicant may be subject to the applicant passing a medical examination and/or skill and agility testing.
NOTE: No applicant will be denied employment solely on the grounds of a criminal conviction. The nature of the offense, the severity of the offense, the surrounding circumstances, and the relevance of the offense to the position being applied for may however be considered.
List below three persons that are not related to you that will have knowledge of your work ethic within the past three years.
I herby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that all
answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I fully understand that any omission or misstatement of material fact on this application or on any document
used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed prior to discovery.
I herby authorize this company to thoroughly investigate my references, work record, educational background, and any other maters related to my suitability for employment. I further authorize the references listed to disclose to this company any and all letters, reports, and any other information related to my work record, without giving me prior notice of such a disclosure. In addition, I herby release this company, my former employers, and all other persons, corporations, partnerships and/or associations from any and all claims, demands and liability arising out of or in any way related to such an investigation or disclosure.
I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and this company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or this company, and that no promises or representations contrary to the forgoing are binding
on this company unless made in writing and signed by me and this company's designated representative. I also fully understand that while under employment for Lexmar / LDI, I will be put on a 90 day formal probation under which I can be terminated for any
reason with or without cause.
By initialing , driver acknowledges that piece rate pay includes (1) 30 minute meal break during his/her shift (up to ten hours) and a second
30 minute meal break after 10 hours if applicable, unless waived. The driver also acknowledges that pay includes a 10 minute rest break
every 4 hours worked. Waiver of the second meal break is voluntary and may only be done if: (1) You are working no more than 12 hours;
and (2) You took your first 30 minute meal break. Driver also acknowledges that any mileage, route or piece rate compensation includes
the time for all rest and meal breaks. Please Note: 15 minute pre-trip, 15 minute post-trip, 2 hours at each shipper and consignee, shop
time, time to complete necessary paperwork, and fueling time is included in the mileage and or piece rate.
No application shall be accepted that is not complete. Please ensure that you are properly prepared to
complete this application. This includes full names,
addresses, zip codes, and telephone numbers where
indicated. Incomplete or unreadable applications will be rejected.
NOTE: The U.S.DOT Requires that employment for at least 3 Years and / or Commercial Driving Experience for the past 10 Years be shown.
By my signature appearing below, I certify that I have read and understand this application for employment. It is agreed and understood that pursuant to Section(s) 391.23 and 382.413 FMCSR this company will investigate my background to ascertain any/all information of concern to my employment history in regard to alcohol or controlled substances misuse or abuse. I hereby release this company and all previous employers listed herein of any liability or damages for seeking or providing the legally required information. It is also understood that any negative information provided by a previous employer in regard to drug or alcohol abuse could result in the rejection of this application for employment with this company. It is also agreed that pursuant to 91-508 Fair Credit Reporting Act, this company may seek an Investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. It is further understood that any misrepresentations or deliberate omissions will result in immediate rejection of this application for employment.