*Note: Fill in all applicable information before you hit Submit. Click Submit only once.
First Name:* Last Name:*
Date of Application MM/DD/YYYY

Black Horse Carriers, Inc.
150 Village Court
Carol Stream, Il 60188
In compliance with Federal and State equal employment opportunity laws, qualified applications are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.
To Be Read And Signed By Applicant
I authorize you to make such investigations and inquiries of my personal, employment financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of emplyment has been extended. I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Black Horse Carriers, Inc.

I understand that information I provide regarding current and/or previous employers may be used, and those employers will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e).  I understand that I have the right to:
  • Review information privided by employers;
  • Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
  • Have rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
The Information provided in the Application for Employment is true, correct, and complete.  If I am accepted for employment, any mistatement or omission of fact on this application or provided in any interview may result in my dismissal.  I understand that this Application for Employment and other Company documents are not contracts of employment.

I authorize the company to thoroughly investigate my references, personal history, work record, and other matters related to my suitability for employment.  I also release the Company from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure.

I understand and agree that if I am employed, my employment is for no definite period of time and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company's President.
Accept Signature* Accept Date MM/DD/YYYY*

Terminal
Positions applied for:*
NONE SPECIFIEDAM PM(SAT) PM(SUN) OTR EC PT
SSN:* - -
Current Address:*  
City:*  
State:*  
 		Zip:*  
Previous Address:
City:
State: Zip:
Home phone number: Cell Phone
Other Phone
Do you have the right to work in the United States?
 		Yes No
Date of Birth:*
Have you worked for this company before? Yes No Date of employment MM/DD/YYYY to
Position held Reason for Leaving
Are you now employed? Yes No If not how long since leaving last employment?
May we contact your employer at this time? Yes No
Who referred you? Rate of pay expected?
Have you ever been convicted of a felony? Yes No
If yes, please explain fully and provide dates. Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.
If offered a position with this company when would you be able to start?
Is there any reason you might be unable to perform the essential functions of the job with or without reasonable accommodation for which you have applied (as described in the attached job description)? Yes No
If yes, explain if you wish.

Employment History
All driver applications to drive a commercial motor vehicle in interstate or intrastate commerce must provide the following information on all employers during the preceding 10 years.  List complete mailing address, street number, city, state and zip code.
(Please list employers starting with the most recent first.  Add another sheet if necessary.)
Employer Date MM/DD/YYYY
Name From To
Address Position
City, State, Zip Salary/Wage
Contact Person Reason for Leaving
Phone #
Were you subject to the FMCSRs while employed?
YesNo
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?
Yes No
Employer Date MM/DD/YYYY
Name From To
Address Position
City, State, Zip Salary/Wage
Contact Person Reason for Leaving
Phone #
Were you subject to the FMCSRs while employed?
YesNo
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?
Yes No
Employer Date MM/DD/YYYY
Name From To
Address Position
City, State, Zip Salary/Wage
Contact Person Reason for Leaving
Phone #
Were you subject to the FMCSRs while employed?
YesNo
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?
Yes No
Employer Date MM/DD/YYYY
Name From To
Address Position
City, State, Zip Salary/Wage
Contact Person Reason for Leaving
Phone #
Were you subject to the FMCSRs while employed?
YesNo
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?
Yes No
Employer Date MM/DD/YYYY
Name From To
Address Position
City, State, Zip Salary/Wage
Contact Person Reason for Leaving
Phone #
Were you subject to the FMCSRs while employed?
YesNo
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?
Yes No
Employer Date MM/DD/YYYY
Name From To
Address Position
City, State, Zip Salary/Wage
Contact Person Reason for Leaving
Phone #
Were you subject to the FMCSRs while employed?
YesNo
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?
Yes No
Employer Date MM/DD/YYYY
Name From To
Address Position
City, State, Zip Salary/Wage
Contact Person Reason for Leaving
Phone #
Were you subject to the FMCSRs while employed?
YesNo
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?
Yes No
*Includes vehicles having a FVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicles used to transport hazardous materials in a quantity requiring placarding.

~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 more than 8 passengers (including the driver) or (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE
Nature of Accident
(Head-On, Rear-End, Upset, ETC) 		Fatalities Injuries Hazardous
Material Spill
(1)Last Accident
(2)Next Previous
(3)Next Previous

Location Date MM/DD/YYYY Charge Penalty
(1)contd. Last Accident
(2)contd. Next Previous
(3)contd. Next Previous


Experience and Qualifications - Driver
Driver
License 		State License Number Type Expiration Date MM/DD/YYYY
Have you ever been denied a license, permit or privilege to operate a motor vehicle? YesNo
Has any license, permit, or privilege ever been suspended or revoked? YesNo


Driving Experience
Class of Equipment Type of Equipment Dates From/To Approx No Of Miles (Total)
Straight Truck
Yes
No 		VanTankFlatDumpReefer
Tractor and
Semi-Trailer
Yes
No		 VanTankFlatDumpReefer
Tractor and Two-Trailers
Yes
No		 VanTankFlatDumpReefer
Tractor and Three-Trailers
Yes
No		 VanTankFlatDumpReefer
Motor Coach - School Bus (More than 8)
Yes
No
Motor Coach - School Bus (More than 15)
Yes
No
Other
List States Operated in for Last 5 years:
Show special Courses or training that will help you as a driver:
Which Safe driving awards do you hold and from whom?
Show any trucking, transportation or other experience that may help in your work for this company
List courses and training other than shown elsewhere in this application
List special equipment or technical materials you can work with (other than those already shown)

Education
Choose the Higest Grade Completed High School College
12345678 01234 01234
Last School Attended (Name/City State)

This certifies that this application was completed by me, and that all entries on it and information in it are true and completed to the best of my knowlege.
Signature* Date MM/DD/YYYY*
Email Address
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