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Lotz Trucking

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Lotz Trucking

Services
Drivers
Lotz Team
Truck Shop
Contact

Lotz Driver Application

Lotz New Driver Application 4

Step 1 of 18

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Your Name*
First Last
Position*
Your Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Your Email*
Enter Email Confirm Email
Preferred Method of Contact*

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Date of Birth*
Physical Exam Expiration Date

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Have you lived at another address in the last three years?*
- Yes
- No
Other Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Have you worked for Lotz Trucking Inc. before?*
- Yes
- No
Date Started*
Date Left*
Reason for Leaving*

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Please select the highest grade completed*

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Employment History
Give a COMPLETE RECORD of all employment and self employement for the past three (3) years.
Give a COMPLETE RECORD commercial driving experience for the past ten (10) years.
Please enter employer information
Employer Name (Current or Former)

Start Date
End Date
Position

Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone
Employer Fax
Reason for Leaving
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 requirement of 49 CFR Part 40?

Yes

No
Please click the "+" button above to add additional employers
*Please Ensure you have provided a full work history of the past 10 years in the form above*

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CDL Type*
Licensing State*
Exp. Date*
Endorsements
- Double/Triple Trailers
- Passenger Vehicles
- Tank Vehicles
- Hazardous Materials
*Check all that apply

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List any additional license(s) held in the past three (3) years:
From
To
CDL Type
State
Exp. Date
Endorsements
- Double/Triple Trailers
- Passenger Vehicles
- Tank Vehicles
- Hazardous Materials
*Check all that apply

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Has your permit, license, or privilege to operate a motor vehicle ever been denied, suspended, or revoked?*
- Yes
- No
Please explain:*

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Straight Truck
From
To
Approximate Number of Miles
Tractor & Trailer
From
To
Approximate Number of Miles
Other Equipment
From
To
Approximate Number of Miles
Other Information
List states operated in, for the last five (5) years:
List special courses/training completed (PTD/DDE, HAZMAT, etc.)
List any safe Driving Awards you hold and from whom:

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Have you been involved in a motor vehicle collision (commercial or private vehicle) in the past three (3) years?*
- Yes
- No

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List all collisions in which you are involved (both commercial and private vehicle) during the past three (3) years:
Date of Accident
State
Number of Injuries
Number of Fatalities
Description of Accident

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Do you have any traffic convictions and/or forfeitures (both commercial & private vehicles) during the past three (3) years?*
- Yes
- No

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List Convictions:
Date
Location
Charge
Penalty

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If currently employed may we contact your present employer?*
- Yes
- No
Have you ever been convicted of a felony?*
- Yes
- No
Please explain:*
Have you ever been convicted for DUI, DWI, OUI?*
- Yes
- No
Is there any reason you might be unable to perform the functions of the job for which you have applied?*
- Yes
- No
Please explain:*
Emergency Contact
Name
First Last
Relationship
Phone

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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 applicants’ background to obtain any and all information of concern to the applicants record, whether the same is of record or not, and applicant releases employers and person 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 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.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Acknowledgement*
- I agree to the above statement

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Job References
Job References
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone
Please click the "+" button above to add additional references

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Pre-Employment Notification and Acknowledgment
I understand and acknowledge that I will be required to undergo a urine drug test under the authority of the U.S. Department of Transportation (DOT) and Federal Motor Carrier Safety Administration (FMCSA) prior to being hired or transferred into a safety-sensitive function* as defined in 49 CFR Part 382. I will not be assigned to perform a safety-sensitive function until my urine drug test is released to the employer as a verified negative result.

(*A safety-sensitive function, as described in 49 CFR Part 382.107, includes: all time from the time a driver begins to work or is required to be in readiness to work until the time he/she is relieved from work and all responsibility for performing work. Safety-sensitive functions include: 1) All time at an employer or shipper plant, terminal, facility, or other property, or on any public property, waiting to be dispatched, unless the driver has been relieved from duty by the employer; 2} All time inspecting equipment as required by 49 CFR Parts 392.7 and 392.8 or otherwise inspecting, servicing, or conditioning any commercial motor vehicle at any time; 3) All time spent at the driving controls of a commercial motor vehicle in operation; 4) All time, other than driving time, in or upon any commercial motor vehicle except time spent resting in a sleeper berth; 5) All time loading or unloading a vehicle, supervising, or assisting in the loading or unloading, attending a vehicle being loaded or unloaded, remaining in readiness to operate the vehicle, or in giving or receiving receipts for shipments loaded or unloaded; and 6) All time repairing, obtaining assistance, or remaining in attendance upon a disabled vehicle.)
Applicant's/Drivers Name*
Date*
Have you tested positive, or refused to test, on any DOT pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, a safety-sensitive position in the past two years? Please circle your response below:*
- Yes
- No
Can you provide documentation that you successfully completed the DOT return to duty requirements described in 49 CFR Part 40, Subpart O?*
- Yes
- No
Certificate of Violations
MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall, at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations for parking only) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months. (Section 3912.27)
Driver who have provided information required by Section 383.31 need not repeat that information.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above if the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he shall so certify. (Section 391.27)

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.
Do you have any traffic violations, convictions, forfeited bonds, or collateral during the past 12 months?*
- Yes
- No
If answered yes, please provide a list of violations
Date
Offense
Location
Type of Vehicle Operated
If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation {other than those I have provided under.Part 383} required to be listed during the past 12 months.
State*
Exp. Date
Authorization for Release of Information: Work History and Alcohol & Controlled Substance Information
I hereby authorize the release of any and all information of my work history to Lotz Trucking Inc. for the purpose of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. I understand that information pertaining to test results of Alcohol and Controlled Substances will be required to be obtained under Section 392.413, which states an employer shall request alcohol and controlled substances information from previous employers in accordance with the requirements of 40.25. The information must be obtained no later than 30 days after the first time a driver performs a safety-sensitive function. The information obtained must include.

• Alcohol test with a result of 0.04 or higher alcohol concentration
• Verified positive drug test
• Refusals to be tested (including verified adulterated or substituted drug test results)

I have read the above notice regarding background reports provided to Lotz Trucking Inc. and I understand that if I sign this consent form, Lotz Trucking Inc. may obtain a report of my crash and inspection history as well as my employment history. I hereby authorize Lotz Trucking Inc. and its employees, authorized agents, and/or affiliates to obtain the information authorized above and release my previous employers, including their agents and entities from any liability for release of information requested by Lotz Trucking Inc.
Important Disclosure Regarding Background Reports From the PSP Online Service
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS In connection with your application for employment with Lotz Trucking (“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 F air 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 bus iness 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 PS P 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 without your authorization. AUTHORIZATION If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize Lotz Trucking (“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 no t 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 l 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. NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language. LAST UPDATED 12/22/2015
Release of Drug & Alcohol Testing Information From Co/Previous Employer
In accordance with 49 CFR Part 391.23, the co/previous employer shall release within 30 days, pursuant to this driver's written authorization, the following information for the previous 3 years from the date of application to this employer or date of transfer, which will automatically comply with the requirements in 49 CFR Parts 40 and 382. The co/previous employer shall also release pursuant to this driver's written authorization the following information in accordance with 49 CFR Part 382 301{b){c)•

TO BE COMPLETED BY DRIVER

I understand my co/previous employer listed below may release any drug or alcohol test information in their possession from any other previous employers under Part 40 or other applicable DOT regulations. If I have violated a DOT drug and alcohol regulation, I authorize my co/previous employer to release all documentation of my successful completion of the DOT return to duty requirements, including follow-up tests, to the employer named below. If I successfully completed the DOT return to duty requirements on my own, I agree to provide the documentation to the employer named below. I authorize my previous employer to release all information requested on this form, including drug & alcohol test results, to the subsequent employer named below.
Disclosure
I understand and acknowledge that I will be required to undergo a urine drug test under the authority of the U.S. Department of Transportation (DOT) and Federal Motor Carrier Safety Administration (FMCSA) prior to being hired or transferred into a safety-sensitive function* as defined in 49 CFR Part 382. I will not be assigned to perform a safety-sensitive function until my urine drug test is released to the employer as a verified negative result.

In connection with your application for employment with Lotz Trucking 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 Adminstration (FMCSA).

When the application for employment is submitted person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or 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 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.fincsa.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 without your authorization.
Authorization
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Lotz Trucking Inc. ("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 (S) 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 safe 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.
Date*
Driver's Electronic Signature*
CAPTCHA
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further account holders required by FMCSA to use the I language contained in this Dis9losure and Authorization form to obtain an Applicant's consent. The language must be used in whole, Exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of "employee" contained at 49 C.F.R. 383.5.
Note:
Please allow up to a few minutes for the form to submit.
Phone
This field is for validation purposes and should be left unchanged.

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