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Application Form

Company Name: Kela Transport
Company Address: 1567 E. Sumner Street, Hartford, WI 53027
Location:
I authorize you to make such invetigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment 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 the Company.

"I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contact, 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 provided by current/previous employers;
• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to prospective employer; and
• Have all rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information."
E-Signature*

Type your name here. An in-person signature may also be required.
Written Signature: _________________________________________________________________________________________________________________________________________________________
Name*
Prefix First Last Suffix
Social Security Number: Added upon office visit _________________________________________________________________
Date of Birth*
MM slash DD slash YYYY
Date of Hire*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email
Past 3 Year Residency
Address
Street Address Address Line 2 City State ZIP Code
Number of Years
Address
Street Address Address Line 2 City State ZIP Code
Number of Years
Address
Street Address Address Line 2 City State ZIP Code
Number of Years
Employment History
All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record).
Current Employer
Business Name
Phone
Address
Street Address Address Line 2 City State ZIP Code
Position Held
From..
MM slash DD slash YYYY
To..
MM slash DD slash YYYY
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed?
- Yes
- No
Was your job designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirments of 49 CFT Part 40?
- Yes
- No
Account for period between jobs. Include dates (month/year) and reason.
Second Last Employer
Business Name
Phone
Address
Street Address Address Line 2 City State ZIP Code
Position Held
From..
MM slash DD slash YYYY
To..
MM slash DD slash YYYY
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed?
- Yes
- No
Was your job designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirments of 49 CFT Part 40?
- Yes
- No
Account for period between jobs. Include dates (month/year) and reason.
Third Last Employer
Business Name
Phone
Address
Street Address Address Line 2 City State ZIP Code
Position Held
From..
MM slash DD slash YYYY
To..
MM slash DD slash YYYY
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations** while employed?*
- Yes
- No
Was your job designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirments of 49 CFT Part 40?
- Yes
- No
Account for period between jobs. Include dates (month/year) and reason.
Experience & Qualification
Have you had driving experience within the last 3 years?*
- Yes
- No
Straight Truck
Type of Equipment
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Aprox. Number of Miles
Tractor & Semi Trailer
Type of Equipment
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Aprox. Number of Miles
Tractor - Two Trailers
Type of Equipment
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Aprox. Number of Miles
Tractor - Three Trailers
Type of Equipment
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Aprox. Number of Miles
Motorcoach - School Bus
(Greater then 8 passengers)
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Aprox. Number of Miles
Motorcoach - School Bus
(Greater then 15 passengers)
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Aprox. Number of Miles
Accident History
Have you been involved in an accident within the past 3 years?*
- Yes
- No
Date of Accident
MM slash DD slash YYYY
Nature of Accident
Number of Injuries
Number of Fatalities
Hazardous Material Spill?
Date of Accident
MM slash DD slash YYYY
Nature of Accident
Number of Injuries
Number of Fatalities
Hazardous Material Spill?
Date of Accident
MM slash DD slash YYYY
Nature of Accident
Number of Injuries
Number of Fatalities
Hazardous Material Spill?
Traffic Convinction and Forfeiters
Have you had any traffic convictions and/or forfeiters within the past 3 years.*
- Yes
- No
Date Convincted
MM slash DD slash YYYY
Violation
State of Violation
Penalty
Date Convincted
MM slash DD slash YYYY
Violation
State of Violation
Penalty
License Information
Section 382.21 FMCSR states "No person who operates a commercial motor vehicle shall at anytime have more than one driver's license." I certify that I do not have more than one motor vehicle license, the information for which is listed below.
State*
Driver's License Number*
Expiration Date*
MM slash DD slash YYYY
Applicant Certification
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.
E-Signature

Type your name here.
Written Signature: _________________________________________________________________________________________________________________________________________________________
* Gaps in employment and/or unemployment must be explained.

** Federal Motor Carrier Safety Regulations 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 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantify requiring placarding.

Application Form

Employment History

Experience & Qualification

Accident History

Traffic Convinction and Forfeiters

License Information

Applicant Certification