11140 North Moonbeam Drive, Idaho Falls, Idaho 83401

Phone: (208) 552-7785 Fax: (208) 545-8046

Driver Application

Driver Information

Date*

Driver Name*

First Middle Last

Driver Cell Phone #*

Email*

Enter Email Confirm Email

Date of Birth (DOB)*

Age*

Please enter a number from 18 to 100.

Social Security #*

License #*

License Expiration*

License State*

Medical Card Expiration Date*

Current Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Information

Emergency Contact Name*

First Last

Emergency Contact Phone*

Second Emergency Contact Name

First Last

Second Emergency Contact Phone

Employment History

Have you worked for Pocono Coast West, LLC before?*

Yes

No

From:*

To:*

Reason For Leaving?*

Employment History

Give a Complete Record of all employment for the past 3 years. Start with your most recent job.

Employment History

Company Name

Phone #

Address

Position Held

From (Date)

To (Date)

Subject to FMCSR? (Yes / No)

49 CFR Part 40? (Yes / No)

The last two colums are asking the following questions: 1) Were you subject to the FMCSR's while employed here? 2) Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Driving Experience

Total Refer Miles Driven*

Total Miles under DOT Regulations*

List Special Courses / Training / Endorsements completed:

Accident Record for the past three (3) years:

Date of Accident

Nature (head on, rear end, etc.)

Location (City, State)

# of Fatalities

# People Injured

Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):

Date

Location (City, State)

Charge

Penalty

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*

Yes

No

Has any license, permit or privilege ever been suspended or revoked?*

Yes

No

Have you ever been convicted of a felony?*

Yes

No

If the answers to any questions listed above are “yes”, give details*

Driver Application Consent

To Be Read and Signed by Applicant

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty which will disqualify applicant from employment opportunities with Pocono Coast West, LLC. It is agreed and understood that Pocono Coast West, LLC or its agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employer (Pocono Coast West LLC) from all liability for any damages on account of applicant furnishing such information, or information surfaced from investigative efforts mentioned previously. It is 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 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 application file. It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

Signature*

Name*

First Middle Last

Hidden

Date Signed*

Background Check Authorization and Release Form

I hereby acknowledge and authorize the use of information from my application, including but not limited to my name, social security number, date of birth, and other relevant details provided to Pocono Coast West, LLC. This authorization encompasses the release of information concerning my prior employment, criminal record, credit history, driving record, workers' compensation, educational background, and general character and reputation.

I hereby authorize the release to Pocono Coast West, LLC, any and all information regarding my prior employment, criminal, credit, driving, workers compensation and educational history as well as information regarding my general character and reputation. I release any providers of such information from any liability for providing the information. I understand the information may be reviewed initially and periodically by Pocono Coast West, LLC

I release Pocono Coast West, LLC and their agents and assigns, from any and all demands and/or liabilities that may originate from these investigations, or any demand or liability which may result from any drug testing procedure, or other medical screening procedures conducted by them or their agents, and any person, corporation, company, institute or their agents who may act upon the authority of this release.

I agree falsification may make me ineligible for employment or subject to immediate dismissal, if hired. I further acknowledge that Pocono Coast West, LLC is relying on third party information and I therefore release Pocono Coast West, LLC, my prospective/actual employer, and their respective owners, agents and employees from any and all liability arising out of errors or omissions. I hereby authorize that a photocopy or electronic facsimile of this document shall serve as an original.

Signature*

Name*

First Middle Last

Hidden

Date Signed*

CAPTCHA

Driver's License Photo

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Accepted file types: jpg, png, pdf, Max. file size: 100 MB, Max. files: 1.

Resume / Any other documents you'd like to provide

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Accepted file types: jpg, png, pdf, Max. file size: 100 MB, Max. files: 3.

Additional information

Add any additional information / explanations that you would like the hiring team to know.

Name

This field is for validation purposes and should be left unchanged.