RAVEN TRANSPORT HOLDING 6800 Broadway Avenue Jacksonville, FL 32254 (877) 877-5058 (Toll-Free)
Required fields are indicated by an asterisk *
NOTICE: BY SUBMITTING THIS FORM, YOU ARE AGREEING THAT YOU HAVE READ ALL DOCUMENTATION STATED HEREIN AND AGREE TO ALL POLICIES PROVIDED BY RAVEN TRANSPORT. SUBMISSION OF THIS FORM WILL ACT AS YOUR SIGNATURE THAT ALL YOUR INFORMATION IS CORRECT AND COMPLETE.
How did you hear about Raven Transport
WE ARE AN EQUAL OPPORTUNITY EMPLOYER APPLICANT'S STATEMENT
I understand that if I am hired, my employment will be for no definite period, regardless of the period of payment of my wages. I further understand that I have the right to terminate my employment at any time with or without notice, and the company has the same right. No one other than the Officers of this Company has authority to modify this relationship or make any agreement to the contrary. Any such modification or agreement must be in writing. I understand that the Company reserves the right to require me to submit to a drug test at any time and also reserves the right to require me to submit to an alcohol test and/or medical examination to the extent permitted by law. I authorize the company to investigate my driving record, my criminal record and my credit history, and I understand that an investigative consumer report may be prepared whereby information is obtained through personal interviews with neighbors, friends and others with whom I am acquainted. This inquiry would include information as to my character, general reputation, personal characteristics and mode of living. I understand that I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I further understand that the Company may contact my previous employers and I authorize those employers to disclose to the Company all records and other information pertinent to my employment with them. I also authorize the Company to provide truthful information concerning my employment with it to my prospective employers and I agree to hold it harmless for providing such information. I certify that all of the information that I provide on this application and in any interviews will be true and accurate. I understand that if I am employed and any such information is later found to be false or misleading in any respect, I may be dismissed. DO NOT CONTINUE UNTIL YOU HAVE READ AND UNDERSTAND THE STATEMENT ABOVE
eMail Address........ * Social Security #. A value is required. Invalid format. * First Name.. .. .. . Minimum number of characters not met. A value is required. Middle Name ........ A value is required.Minimum number of characters not met. * Last Name.......... A value is required.
Previous Address Minimum number of characters not met. Previous City....... ...State ...Zip ...Phone A value is requir How Long?..........
Previous Address Previous City...... ...State ...Zip Phone How Long?.........
All driver applicants who drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete maili ng address, street number, city, state, zip code, phone number, and fax number. Applicants who drive a commercial motor vehicle in interstate or intrastate also shall provide an addidtional 7 yearss of employment history for those employers for which the applicant drove a commercial motor vehicle.
* Start Date.................... Format: yyyy-mm-dd (example 2010-02-18) * End Date.................... Format: yyyy-mm-dd (example 2010-02-18) A value is required. Invalid format. Salary........................... Position........................ * Present Employer...... A value is required. * Address..................... A value is required. * City............................ A value is required. * State....... A value is required. * Zip... A value is required. * Phone......................... A value is required. * Fax. Reason for Leaving
Where you subject to the FMCSRs while employed? Yes No
Was your job designed as a safety-sensitive function in any DOT-regulated mode subject to the Drug & Alcohol Testing requiementsof 49VFR Part 40? Yes No
Start Date......... Invalid format.Format: yyyy-mm-dd (example 2010-02-18) A value is required. End Date.......... Invalid format.Format: yyyy-mm-dd (example 2010-02-18) A value is required. Salary............... Position............ Past Employer . Address........... City................. State.... Zip Phone ............. Fax....... Reason for Leaving
Start Date ......... Invalid format.Format: yyyy-mm-dd (example 2010-02-18) A value is required. End Date........... Invalid format.Format: yyyy-mm-dd (example 2010-02-18) A value is required. Salary................ Position............. Past Employer... Address............ City................... State .... Zip Phone............... Fax....... Reason for Leaving
Start Date ...... Invalid format. Format: yyyy-mm-dd (example 2010-02-18) A value is required. End Date........ Invalid format. Format: yyyy-mm-dd (example 2010-02-18) A value is required. Salary............. Position ......... Past Employer Address ........ City................ State ... Zip Phone ........... Fax... ... Reason for Leaving
* Date of Birth................. Format: yyyy-mm-dd (example 2010-02-18) A value is required.Invalid format. Can you provide Proof-of-Age YES NO
Have you ever worked for this company before? YES NO
If Yes, Where and When
Where you referred to us by a Raven Driver? YES NO
If YES, who?
If employed, how would you get to and from work?
*Have you ever pled guilty or "no contest" to a crime or been convicted of a crime? YES NO
If "YES", Dates and Details. *Do you have any criminal charges pending? YES NO
If "YES" Dates and Details
If you answered ''Yes'' to either question, Please give date(s) and details of each: NOTE: Answering ''Yes'' to these questions does not constitute an automatic bar to employment. Only those crimes, which are substantially related to the position you are seeking, will be considered. Have you ever been terminated or asked to resign from a job? YES NO
If "YES", please explain circumstances.
Drivers license information:
* State of License............. A value is required. * Drivers License #.....................
* Type............................. A value is required.Minimum number of characters not met. * License Expiration Date...... Format: yyyy-mm-dd (example 2010-02-18) A value is required.Invalid format. Endorsements/Restrictions
Have you ever been licensed in another State? YES NO If "YES", what State and license number?
Most recent traffic conviction or forfeiture of license (other than parking violations): Location Date...... Invalid format.A value is required.Format: yyyy-mm-dd (example 2010-02-18) Charge.. Penalty.. (Enter traffic violation information here if more space is needed)
Please list your most recent accident: Date Invalid format.A value is required. Format: yyyy-mm-dd (example 2010-02-18) Nature of Accident Fatalities................ Injuries .................
*Has any license, permit or privilege ever been suspended or revoked? YES NO
Have you ever been denied a license, permit or privilege to operate a motor vehicl? YES NO
*Have you ever been cited for DUI or DWI? YES NO
If "YES" to any of these questions, Please explain the circumstances:
*List all States operated in for the last five years A value is required.
Have you attended accredited Driver Training Schools? YES NO
If "YES", what are the names of the schools and legnth of time attended:
Select highest grade completed (junior level) . na 6 7 8
Select highest grade completed (high school) . na 9 10 11 12 Select number of college years attended ......... 1 2 3 4 5 6
Last School Attended: Name............ A value is required. City and State A value is required.
* Lien Holder............... * Year......................... Invalid format. The entered value is less than the minimum required.The entered value is greater than the maximum allowed. * Make........................ * Model....................... * V.I.N........................ * License Plate #.......... * Base State...... * Cost of Vehicle New. * Empty Weight........... * Gross Weight
Will you need to purchase insurance through Raven Transport? Yes No
If "No" then complete the following:
Name of Carrier and Policy Number for:.............. Non-Trucking Use Liability and Physical Damage: Occupational Accident.........................................
NOTE: (Please read) I certify by my signature at the end of this application, that I have read and understand that under Maryland law, an employer may not require or demand any applicant for employment or prospective employment or any employee to submit to or take a polygraph, lie detector or similar test or examination as a condition of employment or continued employment. Any employer who violates this provision is guilty of a misdemeanor and subject to a fine not to exceed $100.00. 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. *(Applicants Signature, type your name in the box) A value is required.
RELEASE OF INFORMATION I authorize the Company to investigate, and parties contacted to release information on my personal, employment, financial, and/or medical history, including workers' compensation claims and other matters as may be necessary in relation to my employment, during the course of my employment. I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with this investigation.
*(Signature, type your name in the box) A value is required.
DISCLOSURE AND RELEASE
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY DAC TO FURNISH THE ABOVE-MENTIONED INFORMATION.
I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which DAC has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that such information which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies, which subscribe to DAC Services.
I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization 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.