Application for Employment
Carthage Marine Transport LLC Date________________
8499 CR 10
Sarcoxie, Mo 64862
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all
positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related
disability, or any other protected group status.
DRIVER, OWNER OPERATOR AND TRUCK OWNER APPLICANT
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 an employment decision. (Generally, inquiries regarding medical
history will be made only if and after a conditional offer of employment 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.
In the event of employment, 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 the Company.
I understand that information I provide regarding current and/or previous employers may be used, and those employers
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 re-send 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.
The U. S. Department of Transportation requires that driver applicants state their date of birth (§391.21(b)(2)).
Date of Birth ___________________________ (Month/Day/Year)
Applicant Name _________________________________________________________________________________
( print ) First Middle Last Social Security No.
Current Address ___________________________________________________ Phone ( ____ ) _____________
Street City State Zip Code
Cell (_____ ) _____________
*lf at the above residence less than three years, list below all residences for the past three years. (Attach a separate sheet
if necessary.)
Previous Address _______________________________________________________
Street City State Zip Code
Previous Address _______________________________________________________
Street City State Zip Code
Previous Address _______________________________________________________
Street City State Zip Code
IN CASE OF EMERGENCY NOTIFY _____________________________________ Phone (______ ) ____________
Cell (______ ) ____________
EDUCATION
Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 College: 1 2 3 4
Last school attended____________________________________________________________________________
School Name City/State Page 1
GENERAL
Position applying for: Temporary ______ Part Time _______ Full Time ______
Position applying for: Driver _______Owner Operator _______ Truck Owner_______
Who referred you? ______________________________ Rate of pay expected? ___________________
Are you currently employed? Yes____ No____ If not, how long since leaving last employment? _______________
Have you worked for this company before? Yes____ No_____ If Yes, Dates: From __________To_________
month/year month/year
Previous Position? _________________ Previous Rate of Pay ______ Reason for leaving _____________________
Names of any relatives employed by this company _____________________________________________________
Have you ever worked for this company under another name? Yes____ No____ If Yes, under what name? _________
Have you ever been convicted of a felony? Yes_____ No____ If Yes, please explain
________________________________________________________________________________________________
(Conviction of a crime is not an automatic bar to employment-all circumstances will be considered).
EQUIPMENT INFORMATION FOR TRUCK OWNERS AND OWNER OPERATORS
Tractor Information
Year _________ Make_______________________ Model_____________________ Mileage_________________
Is the tractor Canada legal? Yes____ NO____ (Maximum wheelbase 244 inches & speed limiter set at 65 MPH Maximum)
If No, would you modify tractor to become Canada legal? Yes____ No_____
Has the Tractor had a DOT VEHICLE OOS in the past 3 years? Yes____ No____
If Yes, Please explain approximate dates and reason:________________________________________________
DRIVER QUALIFICATION PERMITS & LICENSES
Drivers licenses Held in last 3 years
State License Number Class Endorsements Expiration Date
____________ _____________ _______ _____________ ____________
____________ _____________ _______ _____________ ____________
Have you been denied a license, permit, or privilege to operate a motor vehicle? Yes___ No___
If Yes, Please explain __________________________________________________________________
Has any license, permit, or privilege ever been suspended or revoked? Yes___ No___
If Yes, Please explain __________________________________________________________________
Do you have passport for Canada? Yes___ No___ If No, any reason one can not be obtained? Yes___ No___
Do you have TWIX card for port entry? Yes__ No__ If No, any reason one can not be obtained? Yes__ No__
DRIVING EXPERIENCE
Type Truck & Trailer Experience
Straight Truck & Trailer Yes ___ No ___ Years Experience ______
Straight Truck & Boat Trailer Yes ___ No ___ Years Experience ______
Tractor & Boat-Trailer Yes ___ No ___ Years Experience ______
Tractor & Flat Bed Yes___ No ___ Years Experience ______
Other Tractor & Semi-Trailer Yes ___ No ___ Years Experience ______ PAGE 2
ACCIDENT RECORD-DOT RECORDABLE ACCIDENTS
(For past 3 years (Attach separate sheet of paper if more space is needed)
Date Location Nature of Accident Fatalities Injuries Vehicles-Towed Hazardous-Material-Spill
City/State Head-On Rear-End, etc Yes-No Yes-No Yes-No Yes-No
_________ __________ ___________________ __ __ __ __ __ __ __ __
_________ __________ ___________________ __ __ __ __ __ __ __ __
_________ __________ ___________________ __ __ __ __ __ __ __ __
_________ __________ ___________________ __ __ __ __ __ __ __ __
ACCIDENT RECORD-(NON DOT RECORDED) INSURANCE REPORTED ACCIDENTS
(For past 3 years (Attach separate sheet of paper if more space is needed)
Date Location Nature of Accident Estimated
City/State Head-On, Rear-End, etc $ Amount Damage Comments
_________ __________ ___________________ _______________ _________________________
_________ __________ ___________________ _______________ _________________________
_________ __________ ___________________ _______________ _________________________
_________ __________ ___________________ _______________ _________________________
TRAFFIC CONVICTIONS AND FORFEITURES
(For past 3 years other then parking violations (Attach separate sheet of paper if more space is needed)
Date Location Charge or Incident
City/State Speeding, Seat Belt, etc $ Amount Penalty Comments
_________ __________ ___________________ _______________ _________________________
_________ __________ ___________________ _______________ _________________________
_________ __________ ___________________ _______________ _________________________
_________ __________ ___________________ _______________ _________________________
DOT OOS
(For past 3 years (Attach separate sheet of paper if more space is needed)
Date Location
City/State Driver or Vehicle OOS Violation Comments
_________ __________ ___________________ _______________ _________________________
_________ __________ ___________________ _______________ _________________________
_________ __________ ___________________ _______________ _________________________
_________ __________ ___________________ _______________ _________________________
SPECIAL TRAINING & AWARDS
Special driving courses or training that you have taken
_______________________________________________________________________________________
Safe driving awards you hold (List awards and from which companies or associations
___________________________________________________________________________________ PAGE 3
EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employers during the
preceding 3 years. Please list complete mailing address; street number, city, state, and zip code, and last known
telephone number: (Note, List employers in reverse order starting with most recent.
Employer
Company Name _________________________________________________________
Address________________________________________________________________
City _____________________________________________________State__________
Contact Person __________________________________________________________
Phone Number _______________________Fax Number _________________________
Position Held _____________________ From (Mo/Yr) _________ To Mo/Yr) _________
Reason for leaving _______________________________________________________
Were you subject to FMCSR regulations while employed? Yes ___ No ___
Was your Job subject to DOT-Regulated Drug & Alcohol Testing requirements of CFR part 40? Yes __ No __
Employer
Company Name _________________________________________________________
Address________________________________________________________________
City _____________________________________________________State__________
Contact Person __________________________________________________________
Phone Number _______________________Fax Number _________________________
Position Held _____________________ From (Mo/Yr) _________ To Mo/Yr) _________
Reason for leaving _______________________________________________________
Were you subject to FMCSR regulations while employed? Yes ___ No ___
Was your Job subject to DOT-Regulated Drug & Alcohol Testing requirements of CFR part 40? Yes __ No __
Employer
Company Name _________________________________________________________
Address________________________________________________________________
City _____________________________________________________State__________
Contact Person __________________________________________________________
Phone Number _______________________Fax Number _________________________
Position Held _____________________ From (Mo/Yr) _________ To Mo/Yr) _________
Reason for leaving _______________________________________________________
Were you subject to FMCSR regulations while employed? Yes ___ No ___
Was your Job subject to DOT-Regulated Drug & Alcohol Testing requirements of CFR part 40? Yes __ No __
Employer
Company Name _________________________________________________________
Address________________________________________________________________
City _____________________________________________________State__________
Contact Person __________________________________________________________
Phone Number _______________________Fax Number _________________________
Position Held _____________________ From (Mo/Yr) _________ To Mo/Yr) _________
Reason for leaving _______________________________________________________
Were you subject to FMCSR regulations while employed? Yes ___ No ___
Was your Job subject to DOT-Regulated Drug & Alcohol Testing requirements of CFR part 40? Yes __ No __
I authorize Carthage Marine Transport LLC 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 an employment decision. I
understand that information I provide regarding current and/or previous employers may be used, and those employers may
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 re-send 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.
APPLICANTS SIGNATURE _____________________________________ DATE ______________ PAGE 4