Employment Application

Please enable JavaScript in your browser to complete this form.

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

SSN# *

Phone *

Email *

Confirm Email *

Confirm Email

Emergency Contact, relationship and phone number: *

PREVIOUS ADDRESS 1 *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

PREVIOUS ADDRESS 2 *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

PREVIOUS ADDRESS 3 *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

OPERATOR LICENSES DRIVING EXPERIENCE *

STATE .................... LICENSE NO. ......................................... TYPE .................. EXPIRATION DATE.........................

CLASS OF EQUIPMENT OPERATED *

TYPE OF EQUIPMENT OPERATED *

DATE(s) FROM DATE(s) TO APPROX. NO. OF MILES (TOTAL) *

DATE FROM ............DATE TO.................... APPROX. NO. OF MILES

ACCIDENT RECORD FOR PAST 3 YEARS *

DATE OF ACCIDENT............. NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)............... FATALITIES ........... INJURIES

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS *

LOCATION.............................................................DATE .........................................CHARGE.............................. PENALTY

Have you ever been convicted of a Felony, OWI, DUI or DWI? *

If yes, please explain

Have you ever tested positive for drugs and/or alcohol? *

If yes, please explain

Past Employment Record - (List ALL past employment for the last 10 yrs. and include ALL DOT regulated past employers) ALL CONTACT INFO FOR EACH EMPLOYER IS REQUIRED; FILL IN ALL THE BLANKS AND ASSURE THERE ARE NO GAPS LONGER THAN 30 DAYS BETWEEN JOBS. START WITH YOUR MOST RECENT POSITION BEFORE APPLYING WITH THIS CARRIER

Last Employer Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Website / URL

Layout

Phone *

Position Held *

From Date...................to Date

Fax *

Reason for Leaving *

Where you subject to U.S. DOT drug & alcohol testing? *

Was this employer regulated by U.S. DOT? *

Second Last Employer Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Website / URL

Phone *

Position Held *

From Date...................to Date

Fax *

Reason for Leaving *

Where you subject to U.S. DOT drug & alcohol testing? *

Was this employer regulated by U.S. DOT? *

Third Last Employer Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Website / URL

Layout (copy) (copy)

Phone

Position Held

From Date...................to Date

Fax

Reason for Leaving

Where you subject to U.S. DOT drug & alcohol testing?

Was this employer regulated by U.S. DOT?

Fourth Last Employer Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Website / URL

Layout

Phone

Position Held

From Date...................to Date

Fax

Reason for Leaving

Where you subject to U.S. DOT drug & alcohol testing?

Was this employer regulated by U.S. DOT?

TO BE READ AND SIGNED BY THE APPLICANT This certifies that this application and any attachment sheets have been completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. *

Date *

Name *

First

Last

GOBT Global PAST EMPLOYMENT SAFETY HISTORY REQUEST. COMPANY EMAIL: office@gobtglobal.com / Please return by faxing or by emailing. Your promptness in this matter is appreciated, thank you. The person named herein has applied with Petra Transportation Inc, for employment in a safety sensitive position.

Name *

First

Middle

Last

I_________________________________________________________________________the listed applicant ABOVE, hereby authorizes the carrier listed below to release all records of employment, including assessments of my job performance, ability, fitness and drug testing results to GOBT Global. I hereby release this company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing the following information to the above-mentioned company. The applicant’s signature on this form releases all liability of you and your company. Information is being requested in accordance with 49 CFR Parts 40, 382 and 391.

Date *

Company Name *

Phone *

Fax *

Company Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Name Of Applicant *

Social Security Number *

Dates of Employment / From: / / / To: / / / *

Full Time /Part Time *

Full Time
Part Time

Position(s) Held: *

Multiple Choice *

Local
Regional
Over The Road
All Of Above

Did this Operator operate commercial motor vehicles greater than 26,000 lbs GVWR? *

Type of Equipment Operated: *

Dry Van
Reefer
Flat-Bed
Other

Reason for Leaving: *

Voluntary
Lay-Off
Terminated
Retired

If Terminated, why?

Eligible for Rehire? *

YES
NO
Upon Review
No, Company Policy

Motor Vehicle Accident/Equipment Damage/Incident Inquiry, If no accidents please check box

No Accidents

Accident Date City, State Did the Accident Involve? Brief Description

Tow ...........Injury.......... Fatality.......... HM Release

Has this Operator ever had a breath alcohol test within the past 3 years a result of 0.04 or higher alcohol concentration? *

Has this Operator ever had a positive drug test in the past 3 years? *

Has this Operator refused a controlled substance test and/or alcohol test within the past 3 years? *

Has this Operator violated any other DOT drug/alcohol regulation? *

If yes, please explain the violation

Have you ever received information from a previous employer that this Operator violated any DOT drug and alcohol regulations? *

Reason for test(s):

Result of test(s):

If the applicant tested positive, to your knowledge, have they satisfactorily completed all return to duty and follow-up testing requirements in accordance 49 CFR 382.503? *

Any other remarks:

Verification Completed By: *

Title: *

Phone *

Date / Time *

Date

Time

First Request Date:

Multiple Choice *

Fax
Mail
Phone

Second Request Date:

Multiple Choice *

Fax
Mail
Phone

Third Request Date:

Multiple Choice *

Fax
Mail
Phone

Operator's Name: *

First

Middle

Last

Date / Offense Location/ Type of Vehicle Operated *

Date of Certification

I have reviewed the driving record and safety history of the above named Operator in accordance with 49 CFR Part 391 and determined that the Operator: *

Meets minimum safe driving requirements
Is disqualified to drive a commercial motor vehicle pursuant to 49 CFR 391.15 or does not meet our safety fitness standards

Date of Review *

Reviewer's Title *

(For Newly Hired Operators) INSTRUCTIONS: Motor carriers when using an operator for the first time shall obtain from the operator a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such Operator was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form. This form is maintained in the driver’s qualification file for a period of six months from hire date.

Operator’s Name: *

First

Middle

Last

Social Security Num. *

Operator’s License State: *

License Number: *

License Class: *

Class A.
Class B.
Class C.

Endorsement(s): *

NONE
(P) Passenger Transport Endorsement
(S) School Bus/Passenger Transport Combo Endorsement
(T) Double/Triples Endorsement
(N) Tank Vehicle Endorsement (Tanker)
(H) Hazardous Materials Endorsement (HAZMAT)
(X) Tanker/HAZMAT Combo Endorsement

Restriction(s): *

NONE
E Restriction
L Restriction
M Restriction
N Restriction
O Restriction
V Restriction
Z Restriction

Type of License: *

Class A.
Class B.
Class C.

Are you currently working for another employer? *

At this time do you intend to work for another employer while still employed by this company? *

Date *

Motor Carrier's Medical Examiner's National Registry Verification To be completed by safety personnel during prequalification process Motor Carrier Instructions: The requirement to include verification of the National Registry Listing in the Contractor's qualification file was published in the Federal Register April 20, 2012. Beginning May 21, 2014, motor carrier must verify that the medical examiner who is listed on the National Registry. This requirement is prescribed in FMCSA Part 391.23 and 391.51. FMCSA Part 391.23 Investigation and inquiries (m)(1) The motor carrier must obtain an original or copy of the medical examiner's certificate issued in accordance with part 391.43 and any medical variance on which the certification is based, and, beginning on or after May 21, 2014, verify the Contractor was certified by a medical examiner listed on the National Registry of Certified Medical Examiners as of the date of issuance of the medical examiner's certificate, and place the records in the Contractor's qualification file, before allowing the Contractor to operate a CMV. (FMCSA part 391.23(m)(1)) FMCSA Part 391.51 General Requirements for Contractor qualification files. (b)(9) A note relating to verification of medical examiner listing on the National Registry of Certified Medical Examiners required by Part 391.23(m). (Part 391.51(b)(9)) Motor Carrier Verification: The following medical examiner has been verified as being listed on the National Registry of Certified Medical Examiners as of the date of issuance of the medical examiner's certificate for the named Contractor.

Contractors Name: *

First

Middle

Last

Identification Number (last 4 of SSN):

Medical Examiner: *

First

Last

National Registry Number:

Verified By: Motor Carrier Representative Signature (This information is required for DOT Compliance)

First

Last

Date

Applicant’s/Operator’s Name: *

First

Middle

Last

Date

Date *

In accordance with 49 CFR Part 40.25(j) the employer is required to ask the employee: Have you ever tested positive tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? *

Date *

Applicant's Name *

First

Middle

Last

I_______________________________________________________________hereby acknowledge that I have received a copy of GOBT Global. Motor Carrier Drug Testing Program (“Program”), which has been developed pursuant to 49 CFR Part 382. In conjunction with my receiving a copy of the Program, I further acknowledge the following: I will read the Program and fully understand the terms contained therein and the consequences for violating any term of the Program within three days of my hire date. I understand that my compliance with all terms of the Program is a condition of my employment with PGOBT Global. and I agree to abide by all terms of the Program. If a post – accident drug rest is required under the Program and I am seriously injured and unable to provide specimen at the time of the accident, then this Acknowledgment shall be considered my authorization for GOBT Global. or its designated representative to obtain hospital reports and other documents which would indicate whether there were any controlled substances in my system. I authorize the collection site, laboratory and/or medical review officer retained by GOBT Global. to perform any and all functions, which those entities and/or individuals may be, required to perform pursuant to the applicable Federal Department of Transportation regulations. Such authorization shall include, but is not limited to GOBT Global. verification of the use of prescribed medications, obtaining information from the Operator’s physician, hospital, dentist or pharmacist and the reporting of negative test results with a qualifying statement in cases where in an Operator may be taking a legally – prescribed Schedule II drug. I hereby release and hold harmless the Company, GOBT Global. and its employees and agents from any liability whatsoever arising from the Program.

Date *

Date of Issuance of Certificate:

Name of Operator: *

First

Middle

Last

Operator Signature: *

First

Middle

Last

Employee's Name: *

First

Middle

Last

Date *

Optin SMS

I agree to receive SMS notifications and updates from Buzoianu Transportation LLC (“GOBT GLOBAL”). Standard message and data rates may apply.

To opt-out of receiving SMS messages, reply "STOP" to any message. For assistance, reply "HELP".

Employment Application

Links

Contact Details