Cypress Truck Lines Driver Application

Personal Information : Required fields are marked with * sign.
Rehire *
Cypress,conducts all D.O.T. Part 382.301 mandated drug and alcohol test and non D.O.T. drug free workplace hair follicle drug testing (detects illegal drug use in last 6 months )
Social Security * - -
Last Name *
First Name *
Middle Name *
Date of Birth *
Address *
City *
State *
Zip *
Home Phone *
Cell Phone *
Email *
Driving License No *
Source of advertisement *
Height *
Weight *
List Licenses held by state in the last 10 years (ALL)

Has License/Permit ever been denied, suspended, or revoked? Yes        No
Explain

How many accidents have you had?
Rollovers?
Dates & Explanation

How many moving violations in the last 7 years?
Dates & Explanation

Any DUI,DWI,or Open Container Violations Lifetime? Yes        No
Dates & Explanation

Any Drug Arrest,Drug Test or breathalyzer failures, or Refusals Lifetime? Yes        No
Dates & Explanation

Ever been arrested for a Violation of any Law? Yes        No
Dates & Explanation

Ever been terminated or discharged from any company? Yes        No
Dates & Explanation

List any gaps in your work history,Dates & Explanation

TRACTOR TRAILER DRIVING EXPERIENCE :  YEARS :   MONTHS :

EMPLOYMENT HISTORY, INCLUDING UNEMPLOYMENT D.O.T. PART 391.21 (10)

Last Employer:
Name of Company
Contact
Area code-Phone No
Address:
Street
City
State
Zip Code
Employment Dates:
From  Month/Year
To  Month/Year
Terminated Yes        No
Explain Reason for Leaving
T/T Equipment Driven:
Flatbed
Van
Tank
Reefer
Straight Truck
Low Boy
Log
Other

2nd Employer:
Name of Company
Contact
Area code-Phone No
Address:
Street
City
State
Zip Code
Employment Dates:
From  Month/Year
To  Month/Year
Terminated Yes        No
Explain Reason for Leaving
T/T Equipment Driven:
Flatbed
Van
Tank
Reefer
Straight Truck
Low Boy
Log
Other

3rd Employer:
Name of Company
Contact
Area code-Phone No
Address:
Street
City
State
Zip Code
Employment Dates:
From  Month/Year
To  Month/Year
Terminated Yes        No
Explain Reason for Leaving
T/T Equipment Driven:
Flatbed
Van
Tank
Reefer
Straight Truck
Low Boy
Log
Other

4th Employer:
Name of Company
Contact
Area code-Phone No
Address:
Street
City
State
Zip Code
Employment Dates:
From  Month/Year
To  Month/Year
Terminated Yes        No
Explain Reason for Leaving
T/T Equipment Driven:
Flatbed
Van
Tank
Reefer
Straight Truck
Low Boy
Log
Other



To be read and signed by applicant

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.
I authorize Cypress Truck Lines, Inc. its affiliates, agents, and vendors, to make such investigations and inquiries of my personal, employment, financial and other related matters as may be necessary in arriving at an employment decision. Specifically, I understand that consumer reports may be requested. These reports may include the following types of information: previous employers, dates of service, reason for termination, accidents, etc. I further understand that such reports may contain from federal, state or other agencies, information concerning my driving record, criminal record, workers' compensation claims, etc. I hereby release employers, schools, healthcare providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. I further authorize Cypress Truck Lines, Inc. and its affiliates, agents, and vendors, to release any and all information regarding myself to any of its lessees that Cypress Truck Lines, Inc. may consider assigning me to.

You have the right to review information provided to us by your previous employers and have any errors in such information corrected by your previous employer as stated in section 391.23 (i) of the FMCSRs. Should you wish to review this information you must submit a written request to us, your prospective employer, as stated in section 391.23 (i) of theFMCSRs.

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.
By checking this box, I consent to my physical signature and certify that the information is true and correct.


RELEASE & CONSENT FORM HIRERIGHT SERVICES

PART 1 - DOT DRUG AND ALCOHOL RELEASE

I authorize, per 49 CFR Part 40, the release of information from my DOT regulated drug and alcohol testing records by my previous employers to HireRight for the sole purpose of transmitting such records to Cypress Truck Lines, Inc. and its representatives/agents/clients. I authorize the release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of drug and alcohol rule violation(s); and (vi) documents, if any, of completion of return-to-duty process following a rule violation. I hereby authorize my worksite employer to submit copies of my current and future drug test results to the Cypress Truck Lines, Inc. This authorization shall expire if and when my worksite employer is no longer Cypress Truck Lines, Inc.

The information I have authorized HireRight to review involves tests required by the DOT. If any carrier/company/school for whom I was previously employed furnishes HireRight with information concerning items (i) through (vi) above, I also authorize that carrier/company/school to release and furnish the dates of my negative drug and/or alcohol tests with results below 0.04 during the three-year period and the name and phone number of any substance abuse professionals who evaluated me during the past three years.
By checking this box, I consent to my physical signature and certify that the information is true and correct.


PART 2 - CONSUMER REPORT DISCLOSURE AND RELEASE

In connection with your employment or application for employment (including contract for services), consumer reports may be requested from HireRight or other Consumer Reporting Agencies ("CRA"). These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, and drugs/alcohol use. Such reports may contain public record information concerning your driving record, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from Hirerite concerning previous driving record requests made by others from such state agencies and state provided driving records.

You have the right to make a request to CRA, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information and the recipients of any reports on you that Hirerite has previously furnished within the three-year period preceding your request. Cypress Truck Lines Inc. may be contacted by mail at 1414 Lindrose Street, Jacksonville, FL 32206 or by phone (904) 356-9322.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTRACTED BY CRA, TO FURNISH THE ABOVE-MENTIONED INFORMATION. THIS AUTHORIZATION DOES NOT APPLY TO DRUG AND ALCOHOL INFORMATION OBTAINED UNDER PART 1.

I hereby consent to your obtaining the above information from CRA, and I agree that such information which CRA has or obtains, and my employment history (not Drug and Alcohol information without a specific consent by me) with you if I am hired, will be supplied by CRA to other companies which subscribe to CRA. I hereby authorize procurement of consumer report(s). If hired or contracted this authorization, for Part 2 reports only, 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.

By checking this box, I consent to my physical signature and certify that the information is true and correct.


PERSONAL & CONFIDENTIAL CONDITIONAL JOB OFFER & MEDICAL REVIEW

Offeree note: This form is to be completed only after you have been given an offer of employment.

By completing and signing this form I am verifying that I have been presented with a conditional job offer based on the qualifications stated on my application form and during the job interview. I understand that I have been offered a job with your organization conditioned upon completing this form and upon successful review of my former employer references and background check. I understand that any misstatement, omission, falsification, or misrepresentation of fact on this form or any other employment-related form is grounds for withdrawal of the conditional job offer, or termination of employment if assigned to a job. I further understand that this information is considered personal, confidential and medical in nature and will be treated as such by handling it confidentially in strict compliance with the Americans with Disabilities Act.


Have you had any on the job injury? Yes        No
If Yes, for each injury list date of injury, employer at the time, cause of injury, how much time off from work, body part involved, and percentage of disability if applicable
 
Do you have or have you ever had any other injuries or illnesses, not on the job, which resulted in surgery, lost time from work, or hospitalization? Yes        No
If Yes, for each injury/illness list date, cause, body part involved, how much time off from work and if there is any continuing treatment at this time
 
Are you currently taking any prescribed medications? Yes        No
If Yes, list what medications you are currently taking, for what condition you are taking the medication, and any side effects the medications have
 
Do you currently have any medical restrictions, or medical conditions requiring special care?
(i.e. diabetes, seizures, allergic reactions, etc.) 		Yes        No
If Yes, please explain
 
Are you currently under a doctor or chiropractor's care? Yes        No
If Yes, please explain (including type of treatment and current restrictions):
 
Have you ever had any problems affecting your wrists, back, neck, shoulders or knees that would affect your ability to perform the duties of the position with or without reasonable accommodations? Yes        No
If Yes, please explain:

I hereby certify that the information contained on this form is true and correct and that there are no omissions. I authorize any physician, medical facility, past employers, and/or privileged agency by Cypress Truck Lines, Inc. and its agents, affiliates, and vendors, to furnish or verify workers compensation and medical information.

By checking this box, I consent to my physical signature and certify that the information is true and correct.


Essential Job Functions - Commercial Truck Driver (Class A & B)

The following are physical requirements pertaining to the job(s) for which you are applying. These bona fide physical requirements are essential functions of the job and are in addition to the skill, certification, years of experience and other qualifications required to perform the job(s) for which you have applied.

Please be aware that all persons may be required to furnish health condition information, and if necessary, submit to an examination by a company-designated physician. This information will be used to determine appropriate job placement. It shall not be used to disqualify an otherwise qualified person who may have a mental or physical disability.

These statements/questions pertain only to the essential functions of the job for which you are applying.


Can you sit and drive as is required for an 11-hour shift? Yes        No
Can you perform repetitive motion tasks with your hands and wrists? Yes        No
Can you push and pull levers or objects that require 100 lbs. of force or more? Yes        No
Do you have free and continual movement of your legs and feet as required to safely operate a clutch, brake and gas pedal or foot controls of a truck? Yes        No
If required, are you able to you reach and lift 60 lbs. above your head? Yes        No
Can you climb stairs to safely get in an out of a truck or with a load regularly? Yes        No
Can you grip, grasp and twist using your hands and wrists constantly as is required to safely operate the steering, shifting or other mechanical or hydraulic controls of a truck? Yes        No
If required, are you able to lift and move 100 lbs. or more? Yes        No
For any No answers to the above questions, please explain

I understand that any misstatement, omission, falsification, or misrepresentation of fact on this form is grounds for withdrawal of the conditional job offer or termination of employment if already employed.

By checking this box, I consent to my physical signature and certify that the information is true and correct.

Complete application and review for accuracy before clicking submit. Once the application has been submitted it cannot be edited but may be printed for review.



I grant Cypress Truck Lines Inc.permission to request to any and all personal information from my previous employers, to access records, and to search by any other reasonable means to verify my background
I certify this information to be true and correct
      Signature:        Date: 
If you need to explain an accident, incident, occurrence, attach additional information
Please click the "Submit Application" button only once and allow time for the form to process.