Driver Employment Application
Hilltrux Tank Lines Inc.
PO Box 696 200 Rosemont Road
North Jackson, OH 44451
  • APPLICANT: READ AND SIGN BEFORE SUBMITTING THIS APPLICATION

    I understand that the information in this application will be used and that prior employers will be contacted for purposes of investigation as required by section 391.23 of the Motor Carrier Safety Regulations. I authorize my past employers and any others contacted to answer all questions asked by the Company concerning my ability, character, and reputation. I release all such persons and Impact from any liability on account of furnishing such information to Impact.


    I understand the Company also may request or obtain investigative consumer report(s) including information about my character, reputation, personal characteristics and mode of living; that upon my timely written request, the Company will disclose the nature and scope of the investigative report(s) it requested; and that I am entitled to the name and address of the reporting agency making such report(s) if I am denied employment because of such report.


    I understand that I must pass a pre-employment drug test. I also understand that, if I am employed, I will be required to submit to and pass drug and alcohol tests on a reasonable cause and random basis, as well as drug and alcohol testing after any recordable accident or otherwise as may be required or permitted by law or Company policy. I hereby authorize the Company and its medical review officers to release any such drug or alcohol test results to the Company, its attorneys, governmental, regulatory, and law enforcement agencies and personnel, and other such persons as may legally be entitled thereto and I release the Company and its medical review officers from any liability on account of the release of such information.


    I understand that my employment, if any, can be terminated with or without cause, and with or without notice, at any time, at the option of either the Company or myself. I understand that no manager or other representative of Hilltrux Tank Lines Inc. has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.


    I understand that I have the right to review information provided by previous employers, have errors corrected by previous employer and resubmitted to Hilltrux Tank Lines Inc. 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 Hilltrux Tank Lines Inc. in writing within 30-days of my application.


    I certify that I am providing this information and submitting this application solely in order for a driver position with Hilltrux Tank Lines. I understand that I will be considered only for a driving position and that Hillarie Tank Lines Inc. will consider this application active for no more than 30 days. If I do not personally renew this application within 30 days, it will signify that I no longer desire to be further considered for employment.
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  • Contact Information

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  • List 3 Personal References:

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  • DRIVER SELECTION STANDARDS

    Impact selection standards and requirements for hiring drivers include:

    1. Must live within the Hilltrux Tank Lines Inc. hiring area.
    2. Must be at least 23 years old and have at least two years verifiable over the road experience.
    3. Must have CDL License with Hazardous Material endorsement issued by the state in which you reside.
    4. Must be able to meet all applicable D.O.T. regulations
    5. No accidents in the past fours years.
    6. No more than 2 moving violations in the past three years.
    7. No B.A.Cs, D.U.I.s or D.W.Is in the past five (5) years or more than one (1) in a lifetime.
    8. Must pass pre-employment drug test.
    9. * Must be able to meet all legal requirements to drive a commercial truck in the USA.
    10. * No felony convictions in history. Cannot be on probation for any reason.
    11. Must be able to meet Hilltrux Tank Lines work attendance/availability requirements.
    12. Must complete personal interview.
    13. With regard to preventable motor vehicle accidents and moving violations, Hilltrux Tank Lines Inc. reserves the right to
    judge each applicant on an individual basis.

    * These standards may be waived in Hilltrux Tank Lines sole discretion if applicant holds a valid waiver issued by
    Canadian immigration law officials or the U.S. probation office that you report to.
  • Discontinuation of the qualification process will be enforced if you fail the drug screen or falsify the application.
    I have read and agree to the standards presented above.

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  • To submit an application, you will need to account for the last ten (10) years of your activities.

    You will need:
    1. Company names, addresses, phone numbers, and name of person to contact.
    2. All motor vehicle accidents or incidents listed that you have been involved in for the last three (3) years.
    3. All tickets listed in all states and in all vehicles in the last three (3) years.
    4. Beginning and ending dates of employment, self-employment or unemployment (month/year).
    5. If (1) a company you worked for is out of business, (2) you were self-employed, or (3) you were unemployed and not
    drawing unemployment, you will need two (2) personal references with specific dates from two separate individuals or
    businesses (other than a relative)
    6. If you received unemployment benefits, a printout of benefits can be obtained from your employment office.
  • EMPLOYMENT RECORD

    Begin with your present or most recent job and work backward in order, listing your employers for the last three years including all full- and part-time employment, self-employment, military service, and any periods of unemployment. Then continue by providing all employers for the previous seven years, following the three-year period mentioned above, for which you were an operator of a commercial motor vehicle (driving jobs only). Use another sheet of paper if necessary.
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  • LICENSE

    List all drivers licenses held in the past three (3) years.
  • STATE LICENSE NUMBER CLASS/ENDORSEMENTS EXPIRATION DATE
    1
    2
    3
    4
    5
  • TRAFFIC CITATIONS

    Traffic convictions and forfeitures for the past three (3) years on record (if none, write “none”) Truck and Car (other than parking violations)
  • DATE LOCATION (STATE) CHARGE PENALTY
    1
    2
    3
    4
    5
    6
  • MOTOR VEHICLE ACCIDENTS

    Motor Vehicle Accident Record for last 3 years(if none, write none) List all involvement with truck and car including property damage, regardless of fault.
  • DATE TYPE VEHICLE NATURE OF ACCIDENT WHO WAS AT FAULT FATALITIES INJURIES
    1
    2
    3
    4
    5
    6
  • Yes No
    A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
    B. Has any license, permit, or privilege been suspended or revoked?
    C. Have you ever been convicted of any alcohol related driving offense?
    D. Have you ever been convicted for possession, sale, or use of a narcotic drug, amphetamine,
    E. Have you ever been convicted of a crime?
    F. Have you ever tested positive or refused to test on any pre-employment Drug or Alcohol test
  • TYPE OF EQUIPMENT (Van,Tank,Flat,Etc.) DATES (From / To) APPROX. NO. OF MILES (Total)
    Straight Truck
    Tractor and Semi-Trailer
    Tractor Two-Trailers
    Other
  • Yes No
    Get in and out of a semi-truck?
    Get in and out of a semi-trailer?
    Get under unit to perform duties, such as checking brakes and visual inspection of equipment?
    Raise and lower trailer dollies when under a load?
    Apply enough pressure to release fifth wheel pin?
    Sit stationary in a driver’s seat for long periods of time?
    Apply enough pressure to trailer tandem lever to release locking pins when sliding tandems?
    Be on duty the maximum hours allowed by D.O.T. Hours of Service Regulations?
  • EDUCATION

    What is your highest grade completed:
  • MISCELLANEOUS INFORMATION

  • I authorize my past employers and any other person or entity who has drug tested me in the past to release to Hilltrux Tank Lines Inc. the results and information regarding such testing. I further agree that if I am employed by Hilltrux Tank Lines I will submit to physical Examinations, blood and urine tests as requested by the Company.

    I understand that if I am employed by Hilltrux Tank Lines, I will be an employee at will. I will not have any employment contract, but
    instead, I will be hired at the mutual consent of the Company and myself. Under this Arrangement, my employment can be
    discontinued at any time, with or without cause, and with or without notice, at the option of either the Company or myself. I expressly deny that I am contractually bound to the Company, or that the Company is contractually bound to me.

    I understand that the Company may provide me with employee handbooks, employee benefits manuals, and other written materials intended to help employees follow and understand the Company’s work rules, personnel policies, benefits, etc. I also understand that such materials are not contracts, and that the Company may update, supplement, increase, decrease, eliminate, or otherwise change any policies, rules, or benefits as it deems appropriate. If employed, I agree to familiarize myself with such materials as to abide by all present and future rules, policies, or procedures of the Company.

    I understand that no representative of the company has any authority to make any agreement contrary to the foregoing.

    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. I UNDERSTAND THAT ANY MISSTATEMENT OR OMISSION OF INFORMATION IN THIS APPLICATION
    MAY RESULT IN MY DISMISSAL.
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  • REQUEST/CONSENT FOR ALCOHOL AND CONTROLLED
    SUBSTANCE INFORMATION FROM PREVIOUS EMPLOYERS

  • SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

  • , hereby authorized that:

  • May release and forward all information requested by section 2 (below) of this document concerning my Alcohol and Controlled Substances Testing records to:

    Prospective Employer: Hilltrux Tank Lines
    Attention: Mark Gatewood
    Address: 200 Rosemont Rd. P.O.Box 696
    Telephone: 330-538-3700
    City, State, Zip: North Jackson, OH 44451
    Fax: 330-538-3705
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  • This request is in compliance with 49 CFR Part 40.25, which states: Records shall be made available to a subsequent employer upon receipt of a written request from an employee.

  • SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

    If the employee was not subject to 49 CFR Part 40 testing requirements while employed by you, please check here ____ sign below, and return.
    Under 49 CFR Part 391.23e:
  • Yes No N/A
    1. Has this person within the previous three years violated the alcohol and controlled
    2. If this person violated the alcohol and controlled substances prohibitions did they
    3. If this person violated the alcohol and controlled substance prohibitions did they.
    If this person completed a substance abuse program and remained in your employ, did they have any of the following testing violations: a. Alcohol tests with a result of 0.04 or higher alcohol concentration.
    b. Verified positive drug tests.
    c. Refusals to be tested (including verified adulterated or substituted drug test results)
  • PLEASE INCLUDE INFORMATION RECEIVED FROM PREVIOUS EMPLOYERS

    If YES to any of the above question, please provide the name, address, and phone number of the Substance Abuse Professional (SAP) for further reference.
  • Name: ________________________________________________

    Address: ______________________________________________

    City, State, Zip: ________________________________________

    Telephone: ____________________________________________
  • Completed by (Signature):____________________________________________

    Date: _______________________________________
  • EMPLOYMENT VERIFICATION

    Hilltrux Tank Lines Inc.
    200 Rosemont Rd. P.O. Box 696
    North Jackson, Ohio 44451
    Phone Number 330-538-3700
    Fax Number 330-538-3705
  • You are hereby authorized to give Hilltrux Tank Lines Inc. 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 information provided by previous employers, have errors corrected by previous employer and resubmitted to Hilltrux Tank Lines Inc 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 Hilltrux Tank Lines in writing within 30-days of my application.
  • Hilltrux Tank Lines Inc

    Fair Credit Reporting Act Disclosure Statement

    In accordance with the provisions 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 1, 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 maybe obtain on you for employment purposes. Sections 382.413, 391.23, 391.25 of the Federal Motor Carrier Safety Regulations, requires these reports.
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  • CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

    MOTOR CARRIER INSTRUCTIONS:
    The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

    The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

    DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:

    1. POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license. If you have more than one license, keep the license from your state of residence and return the additional license to the states that issued them. DESTROYING a license does not close the
    record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by the state.

    2. NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to : 1) your employing carrier, and 2) the state that issued your license (if the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing.
  • The following license is the only one I will possess:

  • DRIVER'S CERTIFICATION: I certify that I have read and understand the above requirements.

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  • DRIVER’S RIGHTS UNDER FMCSR 391.23

    As a driver you are provided with certain rights under the Federal Motor Carrier Safety Regulations in Part 391.23. These rights are:

    391.23(i)(1)
    (i) The right to review information provided by previous employers;
    (ii) The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer;
    (iii) The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

    391.23(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three
    years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business day deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

    391.23(j)(1) Drivers wishing to request correction of erroneous information in records received pursuant to paragraph (i) of
    this section must send the request for the correction to the previous employer that provided the records to the prospective
    employer.

    391.23(j)(2) After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer, or notify the driver within 15 days of receiving a driver's request to correct the data that it does not agree to correct the data. If the previous employer corrects and forwards the data as requested, that employer must also retain the corrected information as part of the driver's safety performance history record and provide it to subsequent prospective employers when requests for this information are received. If the previous employer corrects the data and forwards it to the prospective motor carrier employer, there is no need to notify the driver.

    391.23(j)(3) Drivers wishing to rebut information in records received pursuant to paragraph (i) of this section must send the
    rebuttal to the previous employer with instructions to include the rebuttal in that driver's safety performance history.

    391.23(j)(4) After October 29, 2004, within five business days of receiving a rebuttal from a driver, the previous employer
    must:
    (i) Forward a copy of the rebuttal to the prospective motor carrier employer;
    (ii) Append the rebuttal to the driver's information in the carrier's appropriate file, to be included as part of the response for any subsequent investigating prospective employers for the duration of the three-year data retention
    requirement.

    391.23(j)(5) The driver may submit a rebuttal initially without a request for correction, or subsequent to a request for correction.

    391.23(j)(6) The driver may report failures of previous employers to correct information or include the driver's rebuttal as part of the safety performance information, to the FMCSA following procedures specified at Sec. 386.12.

    391.23(k)(1) The prospective motor carrier employer must use the information described in paragraphs (d) and (e) of this section only as part of deciding whether to hire the driver.

    391.23(k)(2) The prospective motor carrier employer, its agents and insurers must take all precautions reasonably necessary to protect the records from disclosure to any person not directly involved in deciding whether to hire the driver. The prospective motor carrier employer may not provide any alcohol or controlled substances information to the prospective motor carrier employer's insurer.

    391.23(l)(1) No action or proceeding for defamation, invasion of privacy, or interference with a contract that is based on the furnishing or use of information in accordance with this section may be brought against--
    (i) A motor carrier investigating the information, described in paragraphs (d) and (e) of this section, of an individual under consideration for employment as a commercial motor vehicle driver,
    (ii) A person who has provided such Information; or
    (iii) The agents or insurers of a person described in paragraph (l)(1)(i) or (ii) of this section, except insurers are not granted a limitation on liability for any alcohol and controlled substance information.

    391.23(l)(2) The protections in paragraph (l)(1) of this section do not apply to persons who knowingly furnish false information, or who are not in compliance with the procedures specified for these investigations.

    I, the undersigned, have received a copy of, read, and understand the above mentioned rights.
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  • Request for State Driving Record

    hereby authorize you to release the following information to Hilltrux Tank Lines, Inc for the purpose of investigation required by Section
    391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information. If hired or contracted, this authorization shall remain on file and shall serve as an ongoing authorization for procurement of the State Driving Record (M.V.R.) as any time during my employment or contract period.
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  • In accordance with the provisions of Sections 604 and 607 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 1 of Public Law 104‐208) I herby certify the following:

    1. The consumer (applicant) has authorized in writing the procurement of this report.

    2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes.

    3. The information requested below will be used for a “permissible purpose” (i.e. information for employment purposes) and will be used for no other purpose.

    4. The information being obtained will not be used in violation of any Federal or State equal opportunity law or regulation.

    5. Before taking and adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer‐reporting agency.
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  • To: _____________________
    From: ___________________

    Dear Sir/Madam:

    …O The following named person has made and application with our company for the position of ____________________________
    _____________________________ In accordance with 391.23, Federal Motor Carrier Safety Regulations, please furnish the
    undersigned with the applicant’s driving record for the past three years.

    O The following named person is an employee with our company in the position of _____________________________
    ________________________ In accordance with 391.25, Federal Motor Carrier Safety Regulations, please furnish the undersigned
    with the applicant’s driving record for the past year.
  • Name Applicant/Driver: __________________________________

    Address: ______________________________________________

    City, State, Zip: ________________________________________

    Date of Birth: __________________________________________

    Social Security Number: __________________________________

    License Number: ________________________________________

    Issuing State: _______________________


    Requested By:

    Print Name: ____________________________________________

    Company Name: ________________________________________

    Signature: _____________________________________________
  • DRIVER APPLICANT PRE‐EMPLOYMENT ALCOHOL AND CONTROLLED SUBSTANCES STATEMENT

    Section 40.25(j) of the Federal Motor Carrier Safety Regulations, requires each motor carrier to inquire of prospective drivers and prospective drivers are requires to respond to the information in the question below.

    Have you, the applicant, tested positive, or refused to test, on any 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 DOT agency drug and alcohol testing rules during the past two years?
  • In addition, if the answer to the above question was YES, please list the name and contact information
    for the Substance Abuse Professional (SAP) who completed your evaluation.

  • If the answer to the above question is YES, please list the motor carrier(s) below:

  • I certify that the information provided on this document is true and correct.

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  • ANTI-DISCRIMINATION POLICY

    Hilltrux Tank Lines, Inc. strives to provide equal employment opportunities for all employees and job applicants without regard to age, race, national origin or ancestry, color, marital status or family responsibility, religion, veteran’s status, gender, physical or mental disability, or other protected classifications, in compliance with federal, state, and local laws governing non-discrimination in employment.

    If you believe you have been discriminated against, you must report the act of
    discrimination to your immediate supervisor. If you feel uncomfortable doing so or if your supervisor is the source of the problem, or ignores the problem, report to Mark Gatewood.

    You are not required to directly confront the person who is the source of your report,
    question, or complaint before notifying any of the individuals listed. Nevertheless, you are required to make reasonable effort to make the discriminatory conduct known should it exist.
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