Job Application

J-Mar Enterprises, Inc.

J-Mar Enterprises, Inc.

Application for Qualification

EDUCATION

GENERAL

DRIVER EXPERIENCE AND QUALIFICATION

EMPLOYMENT RECORD

ALCOHOL/DRUG TESTING

EMPLOYEE'S RIGHTS REGARDING THE INVESTIGATIVE INFORMATION THAT WILL BE PROVIDED TO THE PROSPECTIVE EMPLOYER PURSUANT TO PARAGRAPHS (D) AND (E) OF

SECTION 391.23(i)

REFERENCE DEPARTMENT OF TRANSPORTATION REGULATED EMPLOYMENT DURING PRECEDING THREE YEARS.

RECORD OF RECEIPT OF EMPLOYEE'S RIGHTS REGARDING INVESTIGATIVE INFORMATION PROVIDED TO THE PROSPECTIVE EMPLOYER

PRE-EMPLOYEMENT URINALYSIS CONSENT FORM

PAST EMPLOYMENT VERIFICATION

PRIVACY WAIVER & CERTIFICATION OF IDENTITY

MISCELLANEOUS EXTRA INFORMATION

Application for Qualification

EDUCATION

GENERAL

DRIVER EXPERIENCE AND QUALIFICATION

EMPLOYMENT RECORD

ALCOHOL/DRUG TESTING

EMPLOYEE'S RIGHTS REGARDING THE INVESTIGATIVE INFORMATION THAT WILL BE PROVIDED TO THE PROSPECTIVE EMPLOYER PURSUANT TO PARAGRAPHS (D) AND (E) OF SECTION 391.23(i) REFERENCE DEPARTMENT OF TRANSPORTATION REGULATED EMPLOYMENT DURING PRECEDING THREE YEARS.

RECORD OF RECEIPT OF EMPLOYEE'S RIGHTS REGARDING INVESTIGATIVE INFORMATION PROVIDED TO THE PROSPECTIVE EMPLOYER

PRE-EMPLOYEMENT URINALYSIS CONSENT FORM

PAST EMPLOYMENT VERIFICATION

PRIVACY WAIVER & CERTIFICATION OF IDENTITY

MISCELLANEOUS EXTRA INFORMATION

EMPLOYEE'S RIGHTS REGARDING THE INVESTIGATIVE INFORMATION THAT WILL BE PROVIDED TO THE PROSPECTIVE EMPLOYER PURSUANT TO PARAGRAPHS (D) AND (E) OF

SECTION 391.23(i)

REFERENCE DEPARTMENT OF TRANSPORTATION REGULATED EMPLOYMENT DURING PRECEDING THREE YEARS.

P.O. Box 2219 Fargo, ND 58108-2219 - (701) 277-0039 (800) 446-8283 Fax (701) 277-0502

Licenses

Driving Experience

Accident Review for past 3 years

Traffic Convictions and Forfeitures for the past 3 years other than parking violations

P.O. Box 2219 Fargo, ND 58108-2219 - (701) 277-0039 (800) 446-8283 Fax (701) 277-0502

Licenses

Driving Experience

Accident Review for past 3 years

Traffic Convictions and Forfeitures for the past 3 years other than parking violations

NamePhone () -
FirstMILastCell () -
Current Address
StreetCityStateZip Code
If at the above residence less than three years, list below all residences for the past three years.

StreetCityStateZip Code

StreetCityStateZip Code

StreetCityStateZip Code
Position Applying for Temporary Part Time Full time
Who Referred you? Rate of pay expected?
Have you worked for this company before? Yes No Dates From To
mm/yymm/yy
Where? Rate of pay Position
Reason for leaving
Names of any relatives employed by this company
Are you currently employed? Yes No If not, how long since leaving last employment?

Highest grade completed College
Last school attended
NameAddress

Have you ever been bonded? Name of bonding company
(Answer only if a job requirement)
Have you ever been convicted of a misdemeanor or felony? Yes No
Do you have any pending charges for a misdemeanor, felony or moving violations? Yes No
If yes, please explain fully. Conviction of a crime is not an automatic bar to qualification. All circumstances will be considered.

The U. S. Department of Transportation requires that driver applicants state their date of birth §391.21(o)(2)
Date of Birth (Example: 01/01/1966)

Physical History
The U. S. Department of Transportation requires that all driver applicants pass certain physical tests before they are hired to drive a motor carrier.
FMC9R §391 Subpart E.
Date of last Department of Transportation prescribed physical examination (Example: 01/01/1966)
Have you ever been granted a waiver under section §391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, leg, hand or arm?
Yes No

Email Address
Answer the questions in this section only if applying for driver position

All Drivers Licenses held in past 3 years must be shown

Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No
Has any license, permit or privilege ever been suspended or revoked? Yes No
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes No
If you answered "yes" to any of the above, please give details

Class of Equipment	Type of Equipment (Van, Tank, Flat, Etc.)	Dates From (mm/yy)	To (mm/yy)	Approximate Total Miles
Straight Truck
Tractor and Semi-Trailer
Twin Trailers - LVC's
Other

List states operated in during last five years

List special courses or training that will help you as a driver

List driving awards held and who awards were presented by

Dates	Nature of accident (Head-On, Rear-End, Overturn, Etc)	Fatalities	Injuries
Last Accident
Next Previous
Next Previous

Enter additional occurrences here

Location	Date	Charge	Penalty

Enter additional occurrences here

J-Mar Enterprises, Inc. requires that driver applications show all employment for the past 10 years.

Start with last or current position, including military experience, and work backward.

Current Employer Supervisor's Name
Street Address City State Zip
Position Held From To Salary
mm/yymm/yy
Reason for leaving
Phone () - Fax () -
Were you subject to the FMCSRs while employed by this employer? Yes No
Was your job at this employer designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40? Yes No

Company Supervisor's Name
Street Address City State Zip
Position Held From To Salary
mm/yymm/yy
Reason for leaving
Phone () - Fax () -
Were you subject to the FMCSRs while employed by this employer? Yes No
Was your job at this employer designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40? Yes No

List any additional employment history below:

Have you tested positive, or refused to test, on any drug or alcohol test administered by an employer to which you have applied for, but did not obtain, safety-sensitive transportation work covered by D. O. T. agency drug and alcohol testing rules during the past two years? Yes No (CFR 49 Part 40)

Have you ever tested positive, or refused to test, on any drug or alcohol test administered by an employer when you were employed to perform safety-sensitive transportation work covered by D. O. T. agency drug and alcohol testing rules? Yes No

If yes, list names, addresses and phone numbers of all applicable employers, and dates of drug or alcohol tests and provide documentation of successful completion of the return-to-duty process.
Employer Name Phone () -
Street Address City State Zip
Date of Test

1.	Employee has right to review information provided by previous employers; 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 employer;
2.	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.
3.	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 the prospective employer, which my be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business days deadline will begin when the prospective employer 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 employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

I do here-by sign receipt for Employee's rights regarding the investigative information that will be provided to the prospective employer pursuant to paragraphs (d) and (e) of section 391.23(i).

Initials

I understand that as required by the Federal Motor Carrier Safety Regulations, Title 49 United States Code of Federal Regulations, Section 391.103, and company policy, all prospective drivers must submit to a controlled substance request.

A urine sample will be collected and tested for controlled substance.

I also understand that if I test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle.

The results of the drug tests will be maintained by the Medical Review Officer for the company who will report whether the test results were negative or positive. The results will not be released to any additional parties without my written authorization.

I hereby agree to submit to a drug screen urinalysis.

Initials

I hereby authorize you to release the following information to J-Mar Enterprises, Inc. for the purpose of investigation as required by Section 391.23 and allowed by Section 383.35 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability that may result from furnishing such information.

Initials

Full Name DOB
Aliases Used
Home Address
Street
City State Zip Code

Put any additional information that you didn't have room for on the application, here:

I certify that I have read and understood all of this qualification application. It is agreed and understood that the Carrier or his/her agents may investigate my background to ascertain any and all information of concern to my employment history, whether same if of record or not, and I release employers and other persons names 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 may be conditioned on the results of a physical examination and drug test.

I further certify that I am a genuine applicant for qualification and this application is being submitted solely for the purpose of seeking qualification by the Carrier 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 agree to furnish such additional information and complete such examinations as my be required to complete my qualification file.

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

I also understand that initialing above constitutes as my online signature.

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

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.

It is the company's policy to assure that applicants are employed and that employees are treated during employment, without regard to their race, religion, sex, color, age, national origin, or physical or mental disability.

Please note you cannot sign application online below. When you come in the office, you will be asked to sign and date below.

Applicant Signature Date

License No.

Endorsements(s)

Expiration Date

(Example: 01/01/1966)

(Example: 01/01/1966)

(Example: 01/01/1966)