Driver Application Driver Application Step 1 of 9 11% Name* First Middle Last Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Has this been your address for less than 3 years?*YesNoHome phoneCell phoneEmail Open Position Applying For/Job NumberStarting Salary ExpectationsWork preferenceFull TimePart TimeSeasonal/InternshipAre you currently employed?*YesNoSupervisor nameSupervisor titleSupervisor phoneAre you at least 21 years of age?*YesNoAre you legally entitled to work in the United States?*YesNoAre you eligible to receive any and all permits/licenses by law?*YesNoHave you ever been discharged or asked to resign from a job?*YesNoAre you able to perform the essential functions of the job for which you are applying with or without reasonable accommodation?*YesNoIf no, describe the function(s) that cannot be performed.List past addresses to cover the previous 3 year period.Full addressFrom MM DD YYYY To MM DD YYYY List past addresses to cover the previous 3 year period.Full addressFrom MM DD YYYY To MM DD YYYY List past addresses to cover the previous 3 year period.Full addressFrom MM DD YYYY To MM DD YYYY Driver's License InformationList all licenses held in the last 3 years.StateSelect...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense NumberDateStateSelect...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense NumberDate Job-Related SkillsIndicate your commercial driving experience with appropriate CDL license.Combination Vehicle (Class A)From and toApprox. Mileage DrivenHeavy Straight Vehicle (Class B)From and toApprox. Mileage DrivenSmall Vehicle (Class C)From and toApprox. Mileage DrivenIndicate Current & Previous CDL Endorsements:T Double/Triple TrailersFrom and toExpiration DateN Tank VehicleFrom and toExpiration DateH Hazardous MaterialsFrom and toExpiration DateX Combination tank vehicle/hazardous materialsFrom and toExpiration Date Driver’s Accident InformationList all accidents in last 3 years.Accident #1Date MM DD YYYY DescribeFatalities?YesNoInjuries?YesNoAccident #2Date MM DD YYYY DescribeFatalities?YesNoInjuries?YesNoAccident #3Date MM DD YYYY DescribeFatalities?YesNoInjuries?YesNo Driver’s Traffic Violations ConvictionsList all violations/conviction in last 3 years.Violation #1Date MM DD YYYY ViolationStateSelect...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCommercial VehicleYesNoViolation #2Date MM DD YYYY ViolationStateSelect...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCommercial VehicleYesNoViolation #3Date MM DD YYYY ViolationStateSelect...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCommercial VehicleYesNoViolation #4Date MM DD YYYY ViolationStateSelect...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCommercial VehicleYesNoViolation #5Date MM DD YYYY ViolationStateSelect...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCommercial VehicleYesNoViolation #6Date MM DD YYYY ViolationStateSelect...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCommercial VehicleYesNoHave you ever had any driver’s license denied, suspended, revoked or canceled by any issuing state agency?YesNoState of issuance/explain. Employment HistoryYou must list all employment history for the last 10 years without omission beginning with the most recent in order for your application to be considered complete and acceptable by COI. You must explain any gaps in employment. If owner/operator, list carriers leased to.Past Employer #1Company name City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific PhoneSupervisor nameOK to contact?Select...YesNoDates of employmentJob titleStarting pay rateEnding pay rateReason for leavingWere you subject to CFR part 40 Controlled Substance and Alcohol testing during this period?YesNoWere you subjected to the Federal Motor Carrier Safety Regulations during this period?YesNoPast Employer #2Company name City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific PhoneSupervisor nameOK to contact?Select...YesNoDates of employmentJob titleStarting pay rateEnding pay rateReason for leavingWere you subject to CFR part 40 Controlled Substance and Alcohol testing during this period?YesNoWere you subjected to the Federal Motor Carrier Safety Regulations during this period?YesNoPast Employer #3Company name City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific PhoneSupervisor nameOK to contact?Select...YesNoDates of employmentJob titleStarting pay rateEnding pay rateReason for leavingWere you subject to CFR part 40 Controlled Substance and Alcohol testing during this period?YesNoWere you subjected to the Federal Motor Carrier Safety Regulations during this period?YesNoPast Employer #4Company name City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific PhoneSupervisor nameOK to contact?Select...YesNoDates of employmentJob titleStarting pay rateEnding pay rateReason for leavingWere you subject to CFR part 40 Controlled Substance and Alcohol testing during this period?YesNoWere you subjected to the Federal Motor Carrier Safety Regulations during this period?YesNoPast Employer #5Company name City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific PhoneSupervisor nameOK to contact?Select...YesNoDates of employmentJob titleStarting pay rateEnding pay rateReason for leavingWere you subject to CFR part 40 Controlled Substance and Alcohol testing during this period?YesNoWere you subjected to the Federal Motor Carrier Safety Regulations during this period?YesNoPast Employer #6Company name City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific PhoneSupervisor nameOK to contact?Select...YesNoDates of employmentJob titleStarting pay rateEnding pay rateReason for leavingWere you subject to CFR part 40 Controlled Substance and Alcohol testing during this period?YesNoWere you subjected to the Federal Motor Carrier Safety Regulations during this period?YesNoPast employer #7Company name City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific PhoneSupervisor nameOK to contact?Select...YesNoDates of employmentJob titleStarting pay rateEnding pay rateReason for leavingWere you subject to CFR part 40 Controlled Substance and Alcohol testing during this period?YesNoWere you subjected to the Federal Motor Carrier Safety Regulations during this period?YesNo Commercial Vehicle Driver ApplicantControlled Substance and Alcohol Questionnaire pursuant to 49 CFR part 40.25(j)Date of Birth MM DD YYYY 49 CFR 40.25(j)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, safety sensitive transportation work covered by DOT agency drug & alcohol testing rules during the past two (2) years?YesNoHave you successfully completed the return-to-duty process?YesNoDOCUMENTATION MUST BE PROVIDED AS A CONDITION OF EMPLOYMENT WITH COI AS A DRIVER AND BEFORE ANY SAFETY SENSITIVE TRANSPORTATION FUNCTION IS PERFORMED. EducationSchool #1Name of school City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Grade(s) completedDid you graduate?Select...YesNoMajorSchool #2Name of school City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Grade(s) completedDid you graduate?Select...YesNoMajorSchool #3Name of school City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Grade(s) completedDid you graduate?Select...YesNoMajor **** Please provide a current Motor Vehicle Report from Dept. of Licensing in order to be considered for a position with Connell Oil. For driver applicants of commercial motor vehicles that require a Commercial Driver’s License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25 (j) As a prospective driver employee, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective employer; 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. Driver employees who have previous Department of transportation regulated employment history in the preceding three (3)years, and wish to review previous employer provided investigative information, must submit a written request to the prospective employer, which may be done at anytime, including applying or as late as thirty (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 (5) business day 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 their request to review the records. APPLICANT’S CERTIFICATION I certify that answers given herein are true and complete to the best of my knowledge. I also authorize Connell Oil, Incorporated (“company”) to investigate all statements contained in this application and to request information about me from previous employers, educational institutions, reviewing criminal conviction and driving records, and verifying any other relevant information about me. I expressly authorize my previous employers to provide information and opinions concerning my work & employment record and work habits. Further, I release all parties and persons connected with any requests for information from all claims, liabilities, and damages for whatever reason, arising out of furnishing any information that may be sought in arriving at an employment decision. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in dismissal. AT-WILL EMPLOYMENT I understand that if the company hires me, my employment is at-will, which means that it may be terminated by the company or me at any time, for any reason or no reason. I also understand that this employment at-will policy may not be modified except in writing by the CEO of the company. APPLICANT CONSENT TO DRUG TESTING I understand that a requirement for employment with Connell Oil Incorporated (“company”) is that I cooperate with and successfully complete drug screening for controlled substances. A positive test or lack of cooperation will disqualify me at this time from further consideration for employment and I will not be able to reapply for 6-months. Lack of cooperation includes alteration of my system or the specimen in a manner that prevents accurate testing, including but not limited to drinking excessive liquids. I understand and agree that any offer of employment which the company extends to me is conditioned upon my cooperation and satisfactory results from the drug testing; and if I begin work prior to taking this test or the results of the tests having been received, my employment is contingent on those results. The sample collection, supervision of chain of custody, and testing procedures will be handled by an outside service designated by the company in a manner to insure, to the maximum practical extent, the objectivity and integrity of the process. If there is reason to believe you tamper with, adulterate or in any other way attempt to dilute the specimen, the second specimen will be collected under direct observation of a same gender collection person. By my signature I hereby agree, in the event that I am offered a position with the company, to provide a sample at the designated facility and agree and consent to have such sample tested for the presence of controlled substances. I authorize the release of test results to the company for its use in evaluating me for employment. I release the company from any and all liability and claims incident to the sample taking, testing and the use of the test results.* I Agree Voluntary Applicant Identification Affirmative Action Employer Requirement Federal law requires us to ask for this information. Its purpose is to ensure equal opportunity, and evaluate our good-faith recruiting efforts to attract ethnic minorities, women, veterans of the Vietnam era, and persons with disabilities. Hiring is based on qualifications. Quotas or preferences based on sex, race or ethnicity are prohibited by law. We invite you to VOLUNTARILY identify yourself in the categories below, now or at any time in the future. You are not required to respond. If you decline, it will not subject you to adverse treatment. This is NOT part of your application file, it is confidential, and will be used in conformance with the law.GenderMaleFemaleHispanic or Latino?Select...YesNoPlease select from the following American Indian/Alaska Native Black, African American White/Caucasian Asian, Asian American Hawaiian/Pacific Islander 2 or more races, non-Hispanic
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