Employment Application

Please complete the application below.

Contact Information - Step 1 of 8

Contact Information

First Name *

Middle Name *

Maiden Name

Last Name *

Address - Street *

City *

State *

Zip Code *

How Long at Address? *

Birthdate

Social Security *

Email *

Phone

Previous Residences

Please list your previous three years of residences below.

Address

City

State

Zip Code

How Long at Address?

Address

City

State

Zip Code

How Long at Address?

Address

City

State

Zip Code

How Long at Address?

License Information

Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.

License State *

License Number *

License Class *

Expiration Date *

Accident Record

Please list your accidents for the last 3 years or more.

Accident Date

Nature of Accident

Number of Fatalities

Number of Injuries

Chemical Spills?

Accident Date

Nature of Accident

Number of Fatalities

Number of Injuries

Chemical Spills?

Accident Date

Nature of Accident

Number of Fatalities

Number of Injuries

Chemical Spills?

Additional Accident Information

List All Additional Accidents Formatted - Date / Nature / Fatalities / Injuries / Chemical Spills

Traffic Convictions and Forfeitures

Please list your traffic convictions and forfeitures for the past three years (other than parking tickets).

Date Convicted

Violation

State

Penalty

Date Convicted

Violation

State

Penalty

Date Convicted

Violation

State

Penalty

Additional Traffic Convictions

List All Additional Traffic Convictions Formatted - Date / Violation / State / Penalty

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

Denied License *

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

Suspended License *

Employment History

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the last five years.

How many jobs have you had in the last five (5) years? *

Limit of eight (8) jobs can be added.

Job 1

Employer Name *

Equipment Class *

Employer Phone *

Employer Address

Address Line 1

City

State

Zip Code

Position and Job Description *

From Dates *

To Dates *

Salary or Hourly Rate *

What was your reason for leaving? *

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40

Job 2

Employer Name *

Equipment Class *

Employer Phone *

Employer Address

Address Line 1

City

State

Zip Code

Position and Job Description *

From Dates *

To Dates *

Salary or Hourly Rate *

What was your reason for leaving? *

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40

Job 3

Employer Name *

Equipment Class *

Employer Phone *

Employer Address

Address Line 1

City

State

Zip Code

Position and Job Description *

From Dates *

To Dates *

Salary or Hourly Rate *

What was your reason for leaving? *

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40

Job 4

Employer Name *

Equipment Class *

Employer Phone *

Employer Address

Address Line 1

City

State

Zip Code

Position and Job Description *

From Dates *

To Dates *

Salary or Hourly Rate *

What was your reason for leaving? *

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40

Job 5

Employer Name *

Equipment Class *

Employer Phone *

Employer Address

Address Line 1

City

State

Zip Code

Position and Job Description *

From Dates *

To Dates *

Salary or Hourly Rate *

What was your reason for leaving? *

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40

Job 6

Employer Name *

Equipment Class *

Employer Phone *

Employer Address

Address Line 1

City

State

Zip Code

Position and Job Description *

From Dates *

To Dates *

Salary or Hourly Rate *

What was your reason for leaving? *

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40

Job 7

Employer Name *

Equipment Class *

Employer Phone *

Employer Address

Address Line 1

City

State

Zip Code

Position and Job Description *

From Dates *

To Dates *

Salary or Hourly Rate *

What was your reason for leaving? *

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40

Job 8

Employer Name *

Equipment Class *

Employer Phone *

Employer Address

Address Line 1

City

State

Zip Code

Position and Job Description *

From Dates *

To Dates *

Salary or Hourly Rate *

What was your reason for leaving? *

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40

Fair Credit Reporting Act Disclosure Statement

In accordance with the provision of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23,and 391.25 of the Federal Motor Carrier Safety Regulations.

Applicant Full Name *

First

Middle

Last

Today's Date

FMCSR Agreement

I understand that, as required by the Federal Motor Carrier Safety Regulations 49 CFR Part 382 and company policy, all prospective drivers must submit to a controlled substances test involving collection of a urine sample that will be tested for the following controlled substances: marijuana, cocaine, opiates, amphetamines and phencyclidine (PCP).

I understand that if I test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle. I also understand I will be given a reasonable opportunity to confer with the company’s medical review officer before any positive drug test result is reported to the company.

The results of the drug tests will be maintained by the medical review officer of the company, who will report to the company whether the test result was negative or positive. The results of any tests will not be released to any additional parties, except as provided in §40.37, without my written authorization.

Applicant Full Name *

First

Middle

Last

Today's Date

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

Full Name *

I hereby provide consent to Petro Logistics LLC to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I understand that if the limited query conducted by Petro Logistics LLC indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Petro Logistics LLC without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for Petro Logistics LLC to conduct a limited query of the Clearinghouse, Petro Logistics LLC must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.

Today's Date

Pre-Employment Screening Agreement

During the past (3) three years, have you tested positive on a pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by the Department of Transportation (DOT) drug and alcohol testing rules? *

During the past (3) three years, have you refused to test on a pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by the Department of Transportation (DOT) drug and alcohol testing rules? *

Please provide documentation of your successful completion of the return-to-duty process. *

Applicant Full Name *

First

Middle

Last

Today's Date *

Leave this field empty

Employment Application

Employment Application

Contact Information

Previous Residences

License Information

Accident Record

Traffic Convictions and Forfeitures

Employment History

Job 1

Job 2

Job 3

Job 4

Job 5

Job 6

Job 7

Job 8

Fair Credit Reporting Act Disclosure Statement

FMCSR Agreement

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

Pre-Employment Screening Agreement

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