Form

Dahlsten Truck Lines, Inc.

Phone: 800-228-4313

Fax: 402-762-3592

Personal Information

General Information

Alcohol And Controlled Substances Testing

Alcohol And Controlled Substances Testing Continued

Education, Training, And Skills

Employment Experience

Current or Most Recent Employer Information

Next Most Recent Employer Information

Next Most Recent Employer Information

Next Most Recent Employer Information

Next Most Recent Employer Information

Next Most Recent Employer Information

Driving Experience / Accidents / Violations

Driving Experience / Accidents / Violations Continued

Additional Files

Agree, Read, and Signed by the Applicant

Disclosure and Release

I Authorize,without Reservation, Any Party Or Agency Contacted By HireRight To Furnish The Above-mentioned Information.

IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

P.O. Box 95
Clay Center, NE 68933

Dahlsten Truck Line, Inc. is an equal opportunity employer. We do not discriminate on the basis of race, color, religion, national origin, sex, age, veteran status, or disability in accordance with applicable laws.

Please complete this application in its entirety. We ask that you complete all questions asked, even if you are including a resume. Do not put ”see resume” in any section. Incomplete applications may not be considered. Please draw your signature at the end of the application.

Today’s Date
Job Applying For	Solo Driver Team Driver Student Driver
When can you start work?

Last Name
First Name
Middle Name
Social Security #
Date of Birth
Email Address
Phone #
Address
City
State		Zip Code
Emergency Contact Name
Emergency Contact Address
Emergency Contact Phone #

Have you ever been convicted of a felony?

Yes No

If yes, please explain, including the offense, date, court location, and disposition.

Have you ever been convicted of DWI, DUI, careless or reckless driving, 15 MPH over posted speed limit, leaving accident scene, or using commercial vehicle in commission of a felony?

Yes No	Date

Has your license or privileges to drive ever been suspended or revoked for any reason?

Yes No	Date

Have you ever been convicted of any misdemeanor other than a traffic violation?

Yes No	Date

Have you tested positive for a controlled substance in the last two years?

Yes No

Have you ever refused a required test for drugs or alcohol in the last two years?	Yes No
If you answered yes to any of the above questions, please give the substance abuse professional sname, address, and phone number for further reference

* Disclosure of this information does not necessarily disqualify you from consideration

Type of School	Name and Location	Major (if applicable)	Type of Degree	Did you Graduate?
High/Prep School or GED
Business or Technical School
College
Special Training Courses

List any special skills that you may have that would be beneficial to the position in which you are applying?

Account for all jobs held beginning with your present or most recent employer. Account for all periods of time including part-time, summer, temporary, unemployment, and military service (show rank and date of discharge). If self-employed, give business name and supply business references. Omissions may disqualify you from further consideration for employment and may justify your dismissal if discovered at a later date. Please list in consecutive order. Please do not type 'see resume.' All information must be supplied on this request for the past 10 years of employment.

Dates of Employment (Month/Year)
Company Name
Company Address
Supervisor’s Name
Company Phone w/area code
Starting Salary		Per
Final Salary		Per
Reason for Leaving
Position(s) Held
Duties Performed

Dates of Employment (Month/Year)
Company Name
Company Address
Supervisor’s Name
Company Phone w/area code
Starting Salary		Per
Final Salary		Per
Reason for Leaving
Position(s) Held
Duties Performed

Dates of Employment (Month/Year)
Company Name
Company Address
Supervisor’s Name
Company Phone w/area code
Starting Salary		Per
Final Salary		Per
Reason for Leaving
Position(s) Held
Duties Performed

Dates of Employment (Month/Year)
Company Name
Company Address
Supervisor’s Name
Company Phone w/area code
Starting Salary		Per
Final Salary		Per
Reason for Leaving
Position(s) Held
Duties Performed

Dates of Employment (Month/Year)
Company Name
Company Address
Supervisor’s Name
Company Phone w/area code
Starting Salary		Per
Final Salary		Per
Reason for Leaving
Position(s) Held
Duties Performed

Dates of Employment (Month/Year)
Company Name
Company Address
Supervisor’s Name
Company Phone w/area code
Starting Salary		Per
Final Salary		Per
Reason for Leaving
Position(s) Held
Duties Performed

Straight Truck	Type of Equipment	Length of Experience	Approximate # of Miles
Straight Truck

Tractor & Semi Trailer	Type of Equipment	Length of Experience	Approximate # of Miles
Tractor & Semi Trailer

In what states have you driven regularly?
What awards do you hold for safe driving?

List and explain in detail giving dates and location of all accidents that you have been involved in during the past five years, in any type of vehicle and regardless of whether chargeable or nonchargeable. If you have had no accidents in the past five years, write NONE. FAILURE TO LIST ALL ACCIDENTS MAY RESULT IN YOUR DISQUALIFICATION.
Date	Type Vehicle	Whose Fault?	Fatalities? Yes or No	$ Amount of all damages

I certify the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral in the past five years. If you have had no traffic violations in the past five years, write NONE. FAILURE TO LIST ALL TRAFFIC VIOLATIONS MAY RESULT IN DISQUALIFICATION
Date	Traffic Conviction(s)	City	State	Penalty

Extended answers, a resume or cover letter can be sent to dfleharty@dahlsten.com.

I agreed and understood that any misrepresentation given above shall by considered an act of dishonesty.
I agreed and understood that Dahlsten Truck Line, Inc. or its agents may investigate the applicants background to ascertain any and all information of concern to the applicants record, whether same is of record or not, and applicant releases employers and persons said herein from all liability for any damages on account of his furnishing such information.
I 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 Investigating Consumer Report, including such information regarding my character, general reputation, personal characteristics, and mode of living.
I agree to furnish such additional information and complete such examinations as may be required to complete my employment.
I agreed and understood that this application in no way obligates Dahlsten Truck Lines, Inc. to employ the applicant.
I agreed and understood that if qualified, the driver may be on a probation period during which time he/she may be disqualified without recourse.
I certify that this application was completed by me, and that all entries in it are true and complete to the best of my knowledge

Date

Applicant's Signature

Print your name
Review your signature

Draw Your signature

Clear

Print Name _______________________________________________
Signature _______________________________________________

In connection with my application for employment (including contract for services) with you, I understand that consumer reports which may contain public record information may be requested from HireRight Services, Tulsa, Oklahoma. These reports may include the following type of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers compensation claims, credit bankruptcy proceedings criminal records, etc., from federal, state, and other agencies which maintain such records; as well as information from HireRight concerning previous driving record requests made by others from such state agencies, and state provided driving records.

I have the right to make a request to HireRight, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which HireRight has previously furnished within the two year period proceeding my request. I hereby consent to your obtaining the above information from HireRight, and I agree that such information which HireRight has or obtains, and my employment history with you if I am hired, will be supplied by HireRight to other companies which subscribe to HireRight Services.

I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain in file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

List all drivers licenses that you presently hold or have held in the past 3 years

Expiration Date

Endorsements

In connection with your application for employment with Dahlsten Truck Line, Inc. ("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication. Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Dahlsten Truck Line ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.
I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.
I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.

I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

Print your name Draw Your Signature Clear Print Name _______________________________________________ Signature _______________________________________________	Social Security No.
	Date