Employment Application – Miller Expedited Freight, Inc.

Employment Application

- Step 1 of 12

Our company (“Company”) fully subscribes to the principles of Equal Employment Opportunity. It is our policy to provide employment, compensation, and other benefits related to employment based on qualifications, without regard to race, color, religion, national origin, age, sex, veteran status, genetic information, disability, or any other basis prohibited by federal, state or local law. In accordance with requirements of the Americans with Disabilities Act and applicable federal, state and/or local laws, it is our policy to provide reasonable accommodation upon request during the application process to applicants in order that they may be given a full and fair opportunity to be considered for employment. As an Equal Opportunity Employer, we intend to comply fully with applicable federal, state and/or local employment laws and the information requested on this application will only be used for purposes consistent with those laws. To the extent required by applicable law, The Company maintains a smoke- free workplace.

Company Name: Miller Expedited Freight

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First Name *

Middle Name *

Last Name *

How many years of commercial driving experience do you have? *

We thank you for your interest in working for Miller Expedited Freight, Inc. Currently, we are only able to consider applicants with a minimum of three (3) years driving experience . Rare exceptions are possible for individuals with at least 2 years driving experience. We welcome you to return and apply again when this requirement is met.

Currently, we are only able to fully consider applicants with a minimum of three (3) years driving experience. However, exceptions are possible for individuals with at least 2 years driving experience so we do welcome you to continue your application but please keep in mind that exceptions to this policy are rare.

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Position Applied For: *

Date: *

PERSONAL DATA

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Salary Expectations: *

Date of Birth: *

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Street Address: *

Length of time at current address: *

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City *

State *

Zip Code *

If at the above residence less than 3 years, list below previous residence. Type 'NA' if not applicable.

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Previous Street Address: *

Length of time at previous address: *

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Previous City *

Previous State *

Previous Zip Code *

Phone *

Email *

T-Shirt Size (Select One) *

Small
Medium
Large
X-Large
XX-Large
XXX-Large

Referred to or heard about the position by: *

If you are under 18 years of age, please specify your age: *

(This information will be used only for child labor law purposes)

Are you available and willing to work weekend shifts (Saturday/Sunday)?* *

Note: It is not necessary for you to identify unavailability for work because of religious observance or practice or any other protected classification.
Subsequent to any job offer, we will consider whether a reasonable accommodation can be made.

Please specify which days, if any, you are unavailable: *

Are you available for out of town work?* *

Will you work overtime, if required?* *

Have you ever applied or worked at our Company before? *

Please provide dates: *

(If applicable)

Are you legally authorized to work in the United States? *

Will you now or in the future require sponsorship for employment visa status (e.g.,H-1B visa status)? *

Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire on day one of employment. Every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire on day one of employment. Every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.

Employment History:

Please complete for all full-time or part-time employment beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis. All applicants should start with their most recent job, include military assignments and voluntary employment and provide Seven (7) years of history. (A separate sheet may be attached.) You must explain any gaps in your employment history.

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. Applicants for a commercial motor vehicle (this includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver) or any size vehicle used to transport hazardous materials in a quantity requiring placarding) in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle.

Previous Employer #1

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Previous Employer #1 Company Name: *

Previous Employer #1 Address: *

Previous Employer #1 Name of Supervisor: *

#1 State job titles and describe job duties: *

Previous Employer #1 Contact Methods Available: *

Phone
Fax
Email

Multiple contact methods help speed up application processing time.
At least one contact method is required.

Previous Employer #1 Phone *

Previous Employer #1 Fax: *

Previous Employer #1 Email *

#1 Reason for leaving: *

May we contact? *

Prev Employer #1 Wage/Salary: *

Prev Employer #1 Date From: *

Previous Employer #1 Date To: *

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Subject to FMCSR* while employed #1? *

*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway
in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of
10,001 pounds or more, (2) is designed or used to transport 8 or more passengers (including the driver), OR (3) is
of any size and is used to transport hazardous materials in a quantity requiring placarding.

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? *

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Previous Employer #2

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Previous Employer #2 Company Name:

Previous Employer #2 Address:

Previous Employer #2 Name of Supervisor:

#2 State job titles and describe job duties:

Previous Employer #2 Contact Methods Available: *

Phone
Fax
Email

Multiple contact methods help speed up application processing time.
At least one contact method is required.

Previous Employer #2 Phone *

Previous Employer #2 Fax: *

Previous Employer #2 Email *

#2 Reason for leaving:

#2 May we contact?

Prev Employer #2 Wage/Salary:

Prev Employer #2 Date From:

Previous Employer #2 Date To:

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Subject to FMCSR* while employed #2?

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? #2

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Previous Employer #3

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Previous Employer #3 Company Name:

Previous Employer #3 Address:

Previous Employer #3 Name of Supervisor:

#3 State job titles and describe job duties:

Previous Employer #3 Contact Methods Available: *

Phone
Fax
Email

Multiple contact methods help speed up application processing time.
At least one contact method is required.

Previous Employer #3 Phone *

Previous Employer #3 Fax: *

Previous Employer #3 Email *

#3 Reason for leaving:

#3 May we contact?

Prev Employer #3 Wage/Salary:

Prev Employer #3 Date From:

Previous Employer #3 Date To:

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Subject to FMCSR* while employed #3? *

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? #3 *

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Previous Employer #4

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Previous Employer #4 Company Name: *

Previous Employer #4 Address:

Previous Employer #4 Name of Supervisor:

#4 State job titles and describe job duties:

Previous Employer #4 Contact Methods Available: *

Phone
Fax
Email

Multiple contact methods help speed up application processing time.
At least one contact method is required.

Previous Employer #4 Phone *

Previous Employer #4 Fax: *

Previous Employer #4 Email *

#4 Reason for leaving:

#4 May we contact?

Prev Employer #4 Wage/Salary:

Prev Employer #4 Date From:

Previous Employer #4 Date To:

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Subject to FMCSR* while employed #4? *

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? #4 *

DRIVING HISTORY

(Answer only if driving is a requirement of the job for which you are applying.)

Please provide information on driver licenses or permits held in the past three (3) years.

CURRENT LICENSE:

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License Number *

State of Issuance *

Class *

Endorsements *

Expiration Date *

LICENSE #2:

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License Number #2

State of Issuance #2

Class #2

Endorsements #2

Expiration Date #2

LICENSE #3:

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License Number #3

State of Issuance #3

Class #3

Endorsements #3

Expiration Date #3

LICENSE #4

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License Number #4

State of Issuance #4

Class #4

Endorsements #4

Expiration Date #4

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

Please Explain:

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

Please Explain Why:

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Emergency Contact Name: *

Emergency Contact Phone: *

Accident Record

Please provide information for the past three (3) years or more (Upload document if more space is needed at end of application).

Have you been involved in any motor vehicle related accidents within the last three (3) years? *

Accident #1

Date of Accident

Nature of Accident

Fatalities

Injuries

Hazardous Material Spill

Accident #2

Date of Accident #2

Nature of Accident #2

Fatalities #2

Injuries #2

Hazardous Material Spill #2

Accident #3

Date of Accident #3

Nature of Accident #3

Fatalities #3

Injuries #3

Hazardous Material Spill #3

Accident #4

Date of Accident #4

Nature of Accident #4

Fatalities #4

Injuries #4

Hazardous Material Spill #4

Traffic Convictions

and forfeitures for the past three (3) years (other than parking violations). If none, write none.

Have you had any traffic convictions or forfeitures (other than parking violations) in the past three (3) years? *

Traffic Conviction #1:

Traffic Conviction #1

Location #1 *

Charge #1

Date #1

Penalty #1

Traffic Conviction #2

Location #2

Charge #2

Date #2

Penalty #2

Traffic Conviction #3

Location #3

Charge #3

Date #3

Penalty #3

Traffic Conviction #4

Traffic Conviction #3 (copy)

Location #4

Charge #4

Date #4

Penalty #4

Previous Driving Experience:

Straight Truck:

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Straight Truck Experience: *

Equipment Type: *

Van
Tank
Flat
Dump
Refer

Date From *

Date To *

Approximate number of miles (total) *

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Tractor and Semi-Trailer (TT) Experience:

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Tractor and Semi-Trailer( TT) Experience: *

TT Equipment Type: *

Van
Tank
Flat
Dump
Refer

TT Date From *

TT Date To *

TT Approximate number of miles *

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Tractor with Two Trailers (T2T) Experience:

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Tractor with Two Trailers (T2T) Experience: *

T2T Equipment Type: *

Van
Tank
Flat
Dump
Refer

T2T Date From *

T2T Date To *

T2T Approximate number of miles (total) *

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Tractor with Three Trailers (T3T) Experience:

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Tractor with Three Trailers (T3T) Experience: *

T3T Equipment Type: *

Van
Tank
Flat
Dump
Refer

T3T Date From *

T3T Date To *

T3T Approximate number of miles (total) *

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Motorcoach / School Bus with 8+ Passengers Experience:

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Motorcoach / School Bus 8p+ Experience: *

More than 8 passengers

8p+ Date From *

8p+ Date To *

8p+ Approximate number of miles (total) *

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Motorcoach / School Bus with 15+ Passengers Experience:

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Motorcoach / School Bus 15p+ Experience: *

More than 15 passengers

15p+ Date From *

15p+ Date To *

15p+ Approximate number of miles (total) *

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Other Equipment Type Experience:

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Other Experience: *

Specify Other Equipment Type:

Other Date From

Other Date To

Other Approximate number of miles (total)

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List all states operated in within past 5 years: *

Please indicate any special courses or training that would assist you as a driver:

Which safe driving awards do you hold and from whom?

Education:

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High School:

Graduated: *

Type of Degree Received or Expected :

Name of High School:

High School City:

High School State:

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College or University:

College/University Graduated: *

Type of College/University Degree Received or Expected:

Name of College or University:

College/University City:

College/University State:

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Technical/GED School

Technical/GED Graduated: *

Type of Technical/GED Degree Received or Expected:

Name of Technical/GED School:

Technical/GED School City:

Technical/GED School State:

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Licenses/Certification

or other training received

Licenses/Certification/Other Graduated: *

Type of Licenses/Certification/Other Received or Expected:

Name of Licenses/Certification/Other School:

License/Certification/Other School City:

License/Certification/Other School State:

FAIR CREDIT REPORTING ACT DISCLOSURE & AUTHORIZATION FORM

As an applicant for employment or a current employee of Miller Expedited Freight Co. you are a consumer with rights under the Fair Credit Reporting Act. In the event any of the following circumstances exist, Miller Expedited Freight LLC or an Affiliated Company may choose to obtain and use information contained in either a consumer report or an investigative consumer report from a consumer reporting agency about you when: (1) considering your application for employment, (2) making a decision whether to offer you employment, (3) deciding whether to continue your employment (if you are hired), or (4) making any other employment-related decisions directly affecting you.

A consumer reporting agency is any person, which, for monetary fees, dues, or on a cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing consumer reports to others, such as Miller Expedited Freight Co.

A consumer report means any written, oral, or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing your eligibility for employment purposes.

An investigative consumer report means a consumer report or portion thereof in which information on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your neighbors, friends, or associates reported on or with others with whom you are acquainted or who may have knowledge concerning any such items of information.

In the event an investigative consumer report is prepared, you may request additional disclosures regarding the nature and scope of the investigaion requested as well as a written summary of your rights under the Fair Credit Reporting Act.

AUTHORIZATION

By providing an electronic signature at the end of this applicaiton, you hereby voluntarily authorize Miller Expedited Freight Co. to obtain either a consumer report or an investigative consumer report about you from a consumer reporting agency and to consider this information when making decisions regarding your employment at Miller Expedited Freight Co. You understand that you have rights under the Fair Credit Reporting Act, including the rights discussed above. This report may be delivered in either written or electronic form.

You voluntarily authorize all persons, including current and former employees and supervisors, credit reporting agencies, educational institutions, law enforcement agencies, motor vehicle departments, and municipal state, and federal courts to release information they may have about you to Miller Expedited Freight Co.

You also understand that if you are employed by Miller Expedited Freight Co, this authorization shall remain in effect throughout your employment.

I have read and understand the Fair Credit Reporting Act disclosure & authorization statement above. *

FMCSA Disclosure & Acknowledgement

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with Miller Expedited Freight (“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

By providing an electronic signature at the end of this applicaiton, you agree that the Prospective Employer may obtain such background reports.

You further authorize Miller Expedited Freight (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding your commercial driving safety record and information regarding your safety inspection history.

your electronic signature also signifies that you understand that you are 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. You understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding your suitability as an employee.

You 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. You understand 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. You understand your request will be forwarded by the DataQs system to the appropriate State for adjudication. You understand that 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, you acknowledge it will include all CMV crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, you understand all inspections, with or without violations, will appear on your PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on your PSP report.

You acknowledge that you have read the above Disclosure Regarding Background Reports provided to you by Prospective Employer and understand that if you sign this Disclosure and Authorization via electronic signature at the end of this applicaiton, Prospective Employer may obtain a report of your crash and inspection history. You 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.
NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49 C.F.R. 383.5.L

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

By providing your electronic signature at the end of this applicaiton, you further hereby provide consent to Miller Expedited Freight, INC.,( MEFI) to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. You understand that if the limited query conducted by MEFI indicates that drug or alcohol violation information about you exists in the Clearinghouse, FMCSA will not disclose that information to MEFI without first obtaining additional specific consent from you. You further understand that if you refuse to provide consent for MEFI to conduct a limited query of the Clearinghouse, MEFI, must prohibit you from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.

I have read and understand the FMCSA disclosures & authorization statements above. *

Brand's Truck Insurance Request For Driving Record

By providing your electronic signature at the end of this application, you authorize and request Brands Insurance or any other approved 3rd party vendor to request a copy of your driving record so that you can be considered for employment by Miller Expedited Freight.

You further authorize Brands Insurance to forward a copy of your driving abstract to the insurance company that underwrites the coverage for your potential employer.

I have read and understand the Brand's Insurance disclosure & authorization statement above. *

Upload your resume or any additional paperwork necessary

Click or drag a file to this area to upload.

By providing your signature below, you acknowledge all preceding disclosures and authorize all preceding authorizations as disclosed above. You provide further authorization for Miller Expedited Freight to use this signature for any purpose directly associated with your application for employment.

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Printed Legal Name *

Signature *

Social Security Number *

Signature Date *

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