Join the Viper Logistics Team Fill out the Application below to be considered for a position at Viper Logistics Viper Job Application First Name * Middle Name * Last Name * Phone # * Email Address * Date of Birth * Social Security # * Date of Application * Position Applied For * Date Available For Work * Do you have a legal right to work in the US? * Yes No Who referred you to Viper Logistics? Current Address * Current Address * # of Years at Address * Previous Address Previous Address # of Years at Address Previous Address Previous Address # of Years at Address License Information (State) * License # * Type/Class * Endorsements * Expiration Date * Previous License Information (State) License # Type/Class Endorsements Expiration Date Driving Experience (Class of Equipment) * No Experience Straight Truck Tractor & Semi-Trailer Tractor & 2 Trailers Tractor & Tanker Type of Equipment Date From Date to Approx # of Miles Driving Experience (Class of Equipment) No Experience Option 1 Type of Equipment Date From Date to Approx # of Miles Date of Accident Violation State of Violation Penalty Date of Accident Violation State of Violation Penalty Date of Accident Violation State of Violation Penalty Have you ever been denied a license, permit, or privilege to operate a motor vehicle? * Yes No If yes, explain Has any license, permit, or privilege ever been suspended or revoked? * Yes No If yes, explain Current Employer Name * Current Employer Phone Number * Current Employer Address * Position Held * From MO/YR * To MO/YR * Reason for Leaving * Salary * Explain Any Gaps in Employment (Include month/year & reason) While employed here, were you subject to the Federal Motor Carrier Safety Regulations? * Yes No Was the job designated as a safety-sensitive function in any Department of Transportation regulated mode subject to alcohol and controlled substances testing as required by 49 CFR 40? * Yes No Second Employer Name Second Employer Name Second Employer Phone Number Second Employer Address Position Held From MO/YR To MO/YR Reason for Leaving Salary Explain Any Gaps in Employment (Include month/year & reason) While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No Was the job designated as a safety-sensitive function in any Department of Transportation regulated mode subject to alcohol and controlled substances testing as required by 49 CFR 40? Yes No Third Employer Name Third Employer Name Third Employer Phone Number Third Employer Address Position Held From MO/YR To MO/YR Reason for Leaving Salary Explain Any Gaps in Employment (Include month/year & reason) While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No Was the job designated as a safety-sensitive function in any Department of Transportation regulated mode subject to alcohol and controlled substances testing as required by 49 CFR 40? Yes No Highest Level of Education * High School College Other School Name & Location * Course of Study * Graduate * Yes No Details Other Qualifications Please list the hours you have worked over the last 8 days: To Be Read and Signed by Applicant I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior employers may be used, and those employers(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to: – Review information provided by current/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 This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations. Applicant Name (Printed) By Entering your Printed name you are confirming submission of this job application. * If you are human, leave this field blank. Submit
