HOME ABOUT US SERVICES DRIVERS CONTACT ESEN DRIVER'S APPLICATION JLM LOGISTICS, INC AUTHORIZATION (SIGN AND DATE BELOW) I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at a decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer 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 application. I understand that false or misleading information given in my application or interview (s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of JLM LOGISTICS, INC. I understand that information I provide regarding current and/or previous employers may be used, and those employer (s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d)and(e). I understand that I have the right to: • Review information provided by previous employers; • Have errors in the information corrected by previous employers and for those previous employers to resend the corrected information to the prospective employer; and • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information. All fields with * must be filled PERSONAL INFORMATION Please list all addresses for past 3 years. DRIVING EXPERIENCE Type of Equipment Years of experience Miles driven VEHICLE INFORMATION ACCIDENT RECORDS (Previous Three Years) Accident Dates* Types of accident Fatalities Injuries TRAFFIC CONVICTIONS (Previous Three Years) Location Date Charge LICENSE AND CRIMINAL BACKGROUND A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No B. Has any license, permit or privilege ever been suspended or revoked? Yes No IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS: Have you ever been arrested and/or convicted of a misdemeanor or felony? Yes No If yes, please explain fully. Conviction of a crime is not an automatic ban to employment, all circumstances will be considered PREVIOUS EMPLOYMENT All driver applicants to drive in intrastate commerce must provide the following information on all employers during the preceding 3 years . List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle. Present or Last Employer: Were you subject to the FMCSRs+ while employed? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol testing Requirements of 49 CFR Part 40? Yes No Send HOMEABOUT USSERVICESDRIVERSCONTACT ©2019 JLM Logistics. All rights reserved