Application | Bogie's Express, Inc.

Application

Looking to expand your driving, we have openings for drivers. Complete the application below.

Application for Qualification

Company:

Bogies Express
Address:

1505 Wind Dancer Trail
City:

Tecumseh, MI 49286
The Purpose of this application is to determine whether or not applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulation and the Company above.
Instructions to Applicant
Please answer all questions. If the answer to any question is"No" or "None", do not leave the item blank, but write "No" or "None".
Date*
Position applying for; Check one or enter title in 'other'*
- Contractor
- Driver
- Contractor's Driver
First*
Middle*
Last*
Phone Number*
Emergency Phone Number*
Age*
Date of Birth*
Social Security Number*
*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.
Physical Exam Expiration Date:*
Current & Three Years Previous Addresses:*
From
To
Have you worked for this company before?*
- Yes
- No
If yes, give dates: From
To
Reason For Leaving?
Education History
Please select the highest grade completed:
Grade School*
College
Post-Graduate
Employment History
Give a Complete Record of all employment for the past three years, including any unemployment or self-employment, and all commercial driving experience for the past ten years.
Mo/Yr From*
Mo/Yr To*
Present Or Last Employer Name*
Position Held*
Street Address*
City*
State Zip*
Reason For Leaving*
Phone #*
Were you subject to the FMCSRs* while employed here?*
- Yes
- No
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?*
- Yes
- No
Mo/Yr From
Mo/Yr To
Present Or Last Employer Name
Position Held
Street Address
City
State Zip
Reason For Leaving
Phone #
Were you subject to the FMCSRs* while employed here?
- Yes
- No
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?
- Yes
- No
Mo/Yr From
Mo/Yr To
Present Or Last Employer Name
Position Held
Street Address
City
State Zip
Reason For Leaving
Phone #
Were you subject to the FMCSRs* while employed here?
- Yes
- No
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?
- Yes
- No
Mo/Yr From
Mo/Yr To
Present Or Last Employer Name
Position Held
Street Address
City
State Zip
Reason For Leaving
Phone #
Were you subject to the FMCSRs* while employed here?
- Yes
- No
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?
- Yes
- No
Mo/Yr From
Mo/Yr To
Present Or Last Employer Name
Position Held
Street Address
City
State Zip
Reason For Leaving
Phone #
Where you subject to the FMCSRs* while employed here?
- Yes
- No
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?
- Yes
- No
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vechicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or use to transport nine or more passengers, or (3) is of any size, use to transport hazardous materials in a quantity requiring placarding.
Driving Experience
Class of Equipment
Straight Truck
Date From
Date To
Approximate number of miles (total)
Tractor and Semi-Trailer
Date From
Date To
Approximate number of miles (total)
Tractor-two Trailers
Date From
Date To
Approximate number of miles (total)
Tractor-three Trailers (Triples)
Date From
Date To
Approximate number of miles (total)
Others
Date From
Date To
Approximate number of miles (total)
List states operated in, for the last five years:

"Click (+) to add list"
List special courses/training completed (PTD/DDC. Haz Mat, etc.):

"Click (+) to add list"
List any safe driving awards you hold and from whom:

"Click (+) to add list"
Accident Record for past three years
Date of Accident
Nature of Accident
Location of Accident
# of Fatalities
# of people injured
Date of Accident
Nature of Accident
Location of Accident
# of Fatalities
# of people injured
Date of Accident
Nature of Accident
Location of Accident
# of Fatalities
# of people injured
Traffic Convictions and Forfeitures for he last three years (other than parking violations)
Date
Location
Charge
Penalty
Date
Location
Charge
Penalty
Date
Location
Charge
Penalty
Driver's License (List each driver's license held in the past three years)
State*
License #*
Type*
Endorsements*
Expiration Date*
State
License #
Type
Endorsements
Expiration Date
State
License #
Type
Endorsements - others than above
Expiration Date
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
- Yes
- No
B. Has any license, permit or privilege ever been suspended or revoked?*
- Yes
- No
C. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job discription)?*
- Yes
- No
D. Have you ever been convicted of a felony?*
- Yes
- No
If the answers to A, B, C or D is "Yes", give details
Personal References
List three persons for references, other than family members, who have knowledge of your safety habits.
First Name*
Last Name*
Address*
Phone*
First Name
Last Name
Address
Phone
First Name
Last Name
Address
Phone
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.

It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information.

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 agreed to furnish such additional information and complete such examination as may be required to complete my application.

It is agreed and understood that this Application for Qualification 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.

This certifies that this application was completed by me, and that all entries on it and information in it are true and compete to the best of my knowledge.
Endorsements - HazMat, Tanker or Other*
- HazMat
- Tanker