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Delivering Reliable Service With Every Flatbed Load

Employment Application

D&E Transport, LLC. works very hard to provide the best possible service to the trucking industry so that we can provide the most opportunities to our drivers. We firmly believe that YOU, the driver makes it all possible for us.

Please fill out the application below to be considered for employment. If you have any questions or concerns, please contact us.

General Information

Position Applying for*
Date of Application*
Referral Source If someone referred you to D&E, please enter their name.
 
First Name*
Middle
Last Name*
Address
City*
State*
Zip*
Home Phone*
Cell Phone
Email Address
Emergency Number
Date of Birth*
Social Security Number*

If above address is less than three years list all addresses in the past three years
Address 
City
State
Zip
Dates From To

Employment Information

List All Driver's Licenses Held for the past Three Years
State   Number Expiration Date
State   Number Expiration Date
State   Number Expiration Date

Experience
Tractor Trailer?*      Dates From To Approx. Miles
Trailers: List all types of trailers pulled and approximate miles for each
Type   Miles           Type Miles
Type   Miles           Type Miles
Any other heavy equipment operation experience like Farm or Construction Equipment?*   
If Yes, please describe Dates From To
Check which best describes your experience with Flatbed Cargo Securement and the Federal Regulations which apply to it*
     
Do you have a TWIC card?*   
DOT Medical Certificate Expiration Date

Accidents
List all Accidents in the past three years (If none, enter NONE).
Date   Injuries Fatalities Describe
Date   Injuries Fatalities Describe
Date   Injuries Fatalities Describe

Freight Claims
List any Freight Claims (damaged, lost or stolen) you've had in the past three years (If none, enter NONE).
Date   Type of Freight Describe
Date   Type of Freight Describe
Date   Type of Freight Describe

Traffic Violations
List all traffic convictions in the past three years (If none, enter NONE).
Date   Violation Commercial Vehicle?   
Date   Violation Commercial Vehicle?   
Date   Violation Commercial Vehicle?   
Have you ever had any driver's license denied, suspended, revoked or canceled by any issuing state agency?*   
If Yes, list state of issuance and explain

Employment History

Last 10 years (383.35). Independent Contractors list Carriers leased to. Start with most current and go back.

Most Recent Employer*
Dates From To
Address
City
State
Zip
Phone
Fax
Were you subject to Federal Motor Carrier Safety Regulations during this period?
Subject to 49 CFR part 40 Controlled Substance and Alcohol Testing during this period?
Position Held
May we contact for reference?
Reason for leaving


Comments (including explanation of any gaps in employments)

Equipment (Owner Operators Only)

Equipment Description (Tractor)
Type
Year
Make
VIN

Equipment Description (Trailer)
Type
Year
Make

Employment Verification

Applicants Name*
Social Security Number*

You are hereby authorized to give D & E Transport, LLC all information concerning records of Employment, including oral assessments of my job performance, ability, and fitness, to each and every company (or their authorized agents) which may request such information in connection with my application for DOT qualification. You are released from any liability, which may result from giving such information; I understand that the information in this form will be used and that prior employers will be contracted for purposes of investigation as required by 391.23 of the Motor Carrier Safety Regulation. I authorize the release of any information related to my alcohol and controlled substance testing and training records, by any former employers and hold them harmless of any liability from release of said information.

I understand that I have the right to review the information provided by my previous employers, have errors corrected by previous employers and resubmitted to D & E and/or have a rebuttal statement attached to erroneous information if my previous employer and I cannot agree on the accuracy of the information. I understand that I must request past employer information obtained by D & E in writing within 30 days of employment or denial of employment.

Electronic Signature Android users: zoom out all the way to sign

Section I
Employee Name*
Employee SS or ID #*

I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer, listed in Section I-B, to the employer listed in Section I-A. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released in Section II-A by my previous employer, is limited to the following DOT-regulated testing items:

  1. Alcohol tests with a result of 0.04 or higher;
  2. Verified positive drug tests;
  3. Refusals to be tested;
  4. Other violations of DOT agency drug and alcohol testing regulations;
  5. Information obtained from previous employers of a drug and alcohol rule violation;
  6. Documentation, if any, of completion of the return-to-duty process following a rule violation.

Electronic Signature Android users: zoom out all the way to sign
Date

Drug Testing Consent

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 test will not be released to any additional parties, except as provided is subsection 40.34, without my written authorization.

I hereby agree to submit to a urine drug test.

Applicant's Name
Electronic Signature Android users: zoom out all the way to sign
Date

DOT Drug and Alcohol Release

In accordance with DOT Regulation 49 CFR Part 391.23, I authorize the release of information from my DOT regulated drug and alcohol testing records by the carriers (company/school) listed above to Roadrunner Transportation Systems, Roadrunner Intermodal Services, Bruenger Trucking, D&E Transport, Morgan Southern Inc., R & M Transportation, Inc., CTW Transport, LLC., A&A Express, Central Cal Transportation, Expedited Freight Systems Inc., Sortino Transportation LLC., Wando Trucking Inc., Rich Logistics, Big Rock Transportation, LLC, Midwest Transit, LLC., Active Aero Motor Carrier, LLC., ISI Logistics, LLC., Roadrunner Truckload, LLC., Roadrunner Expedite, Unitrans International Corporation, Stagecoach Cartage and Distribution LLC or Roadrunner Temperature Control and/or HireRight (formerly USIS) and/or Asurint for the sole purpose of transmitting such records to Roadrunner Transportation Systems, Roadrunner Intermodal Services, Bruenger Trucking, D&E Transport, Morgan Southern Inc., R & M Transportation, Inc., CTW Transport, LLC., A&A Express, Central Cal Transportation, Expedited Freight Systems Inc., Sortino Transportation LLC., Wando Trucking Inc., Rich Logistics, Big Rock Transportation, LLC, Midwest Transit, LLC., Active Aero Motor Carrier, LLC., ISI Logistics, LLC., Roadrunner Truckload, LLC., Roadrunner Expedite, Unitrans International Corporation, Stagecoach Cartage and Distribution LLC, or Roadrunner Temperature Control, I authorize release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation(s); and (vi) documents, if any, of completion of a return-to-duty process following a rule violation. The information that I have authorized HireRight and/or Asurint to review involves tests required by DOT. If any carrier (company/school) listed above furnishes HireRight and/or Asurint with information concerning items (i) through (vi) above, I also authorize that carrier (company/school) to release and furnish the dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the three-year period and the name and phone number of any substance abuse professional who evaluated me during the past three years.

Applicant's Name
Electronic Signature Android users: zoom out all the way to sign
Date

Consumer Report Disclosure and Release

In connection with your employment or application for employment (including contract for services) with Roadrunner Transportation Systems, Roadrunner Intermodal Services, Bruenger Trucking, D&E Transport, Morgan Southern Inc., R & M Transportation, Inc., CTW Transport, LLC., A&A Express, Central Cal Transportation, Expedited Freight Systems Inc., Sortino Transportation LLC., Wando Trucking Inc., Rich Logistics, Big Rock Transportation, LLC, Midwest Transit, LLC., Active Aero Motor Carrier, LLC., ISI Logistics, LLC., Roadrunner Truckload, LLC., Roadrunner Expedite, Unitrans International Corporation, Stagecoach Cartage and Distribution LLC. or Roadrunner Temperature Control consumer reports may be requested from HireRight (formerly USIS Commercial Services) and/or Asurint. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, and drugs/alcohol use. Such reports may contain public record information concerning your driving record, workers compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from HireRight and/or Asurint concerning previous driving record requests made by others from such state agencies and state provided driving records.

You have the right to make a request to HireRight and/or Asurint upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information and the recipients of any reports on you that HireRight and/or Asurint has previously furnished within the three-year period preceding your request. HireRight may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma, 74153, or by phone at (800) 381-0645. Asurint may be contacted at Compliance Department P.O. Box 14730, Cleveland, Ohio, 44114 or by phone at 800-906-2034 or by email at compliance@asurint.com.

I AUTHORIZE, WITHOUT RESERVATION, HIRERIGHT, ASURINT AND ANY PARTY OR AGENCY CONTACTED BY HIRERIGHT AND/OR ASURINT TO FURNISH THE ABOVE-MENTIONED INFORMATION. THIS AUTHORIZATION DOES NOT APPLY TO DRUG AND ALCOHOL INFORMATION OBTAINED UNDER PART I.

I hereby consent to your obtaining the above information from HireRight and/or Asurint, and I agree that such information which HireRight and/or Asurint has or obtains, and my employment history (not DOT Drug and Alcohol information without a specific consent by me) with you if I am hired, will be supplied by HireRight and/or Asurint to other companies which subscribe to HireRight and/or Asurint. I hereby authorize procurement of consumer report(s). If hired or contracted, this authorization, for reports covered by this release only, shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment or contract period.

Notice to California Applicants
Under California law, the consumer reports we order on you for employment purposes within the State of California are defined as investigative consumer reports. These reports may contain information on your character, general reputation, personal characteristics and mode of living. Under section 1786.22 of the California Civil Code, you may view the file maintained on you by HireRight and/or Asurint during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services, by appearing at HireRight and/or Asurint in person or by mail. The agency is required to have personnel available to explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.

Name
State of Residence
Social Security Number
Driver's License #
State Licensed in
Date
Electronic Signature Android users: zoom out all the way to sign

Authorization to Receive Driving Record

I hereby authorize D & E Transport, Inc. to obtain a copy of my driving Record (MVR), for the purpose of establishing and maintaining eligibility As a driver/independent contractor, as required by the insurance providers. I release D & E Transport and the provider of my driving record from any and all liability which may result from receiving and furnishing such information.

I hereby authorize Tri State Trucking Insurance to obtain my driving record.

Applicant Name
Date of Birth
License #
State of License
License Expires
Total Years Experience
Electronic Signature Android users: zoom out all the way to sign
Date

Authorization to Receive Federal Motor Carrier Safety Administration Records

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Roadrunner Transportation Systems, Roadrunner Intermodal Services, Bruenger Trucking, D&E Transport, Morgan Southern Inc., R & M Transportation, Inc., CTW Transport, LLC., A&A Express, Central Cal Transportation, Expedited Freight Systems Inc., Sortino Transportation LLC., Wando Trucking Inc., Rich Logistics, Big Rock Transportation, LLC, Midwest Transit, LLC., Active Aero Motor Carrier, LLC., Roadrunner Carrier, LLC., ISI Logistics, LLC., Roadrunner Truckload, Roadrunner Expedite, Unitrans International Corporation, Stagecoach Cartage and Distribution LLC or Roadrunner Temperature Control ("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 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 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 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 Roadrunner Transportation Systems, Roadrunner Intermodal Services, Bruenger Trucking, D&E Transport, Morgan Southern Inc., R & M Transportation, Inc., CTW Transport, LLC., A&A Express, Central Cal Transportation, Expedited Freight Systems Inc., Sortino Transportation LLC., Wando Trucking Inc., Rich Logistics, Big Rock Transportation, LLC, Midwest Transit, LLC., Active Aero Motor Carrier, LLC., Roadrunner Carrier, LLC., ISI Logistics, LLC., Roadrunner Truckload, Roadrunner Expedite, Unitrans International Corporation, Stagecoach Cartage and Distribution LLC or Roadrunner Temperature Control ("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 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.

Applicant's Name
Electronic Signature Android users: zoom out all the way to sign
Date

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.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of "employee" contained at 49 C.F.R. 383.5.

Americans with Disabilities Act

The Civil Rights Act of 1964 prohibits discrimination because of race, color, religion, sex, or national origin. PL90-202 prohibits discrimination because of age. The Americans with Disabilities Act prohibits discrimination because of disability. Note: Read and complete all portions of this proposal. Proposals that are incomplete may be rejected. This application contains many questions which are required by law.

Some of the language may unintentionally tend to portray our proposed relationship as employee, employer. Nothing in this application should be read or understood to undermine the Independent Contractor relationship which is being proposed.

This certifies that this application was completed by me, and that all entries on it and information on it are true and complete to the best of my knowledge.

Applicant's Name
Electronic Signature Android users: zoom out all the way to sign
Date

Document Upload

Please upload the following documents (if available)

Driver's License
Medical Card
Title of Truck
2290
DOT Inspections