Application Form

The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company named above.

Instructions to Applicant

Please answer all questions. If the answer to any question is "No" or "None", do not leave the item blank, but write "No" or "None". This is important.

* The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.
 
Date :
Position applying for; Check One:
Contractor Driver Contractor's Driver
(A) First Name
Middle Name
Last Name
Phone No.
Emergency Phone No.
Email:
* Age
 Date of Birth
Social Security No.
Physical Exam Expiration Date
Current & Previous Address :
1. Current :
From
To
2. Previous :
From
To
(B) Give a Complete Record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past ten years.
From
To
Present/Last Employer Name
Position Held
Address
Reason for Leaving
Phone
Were you subject to the FMCSRs* while employed here? Yes No
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
From
To
Present/Last Employer Name
Position Held
Address
Reason for Leaving
Phone
Were you subject to the FMCSRs* while employed here? Yes No
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
From
To
Present/Last Employer Name
Position Held
Address
Reason for Leaving
Phone
Were you subject to the FMCSRs* while employed here? Yes No
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
From
To
Present/Last Employer Name
Position Held
Address
Reason for Leaving
Phone
Were you subject to the FMCSRs* while employed here? Yes No
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
 
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passenger^, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.
(C) Driving Experience
Class of EquipmentDatesApproximate Number of Miles
 FromTo(Total)
Straight Truck
Tractor and Semi-trailer
Tractor-two trailers
Tractor-three trailers (triples)
Other
(D) List states operated in, for the last five years
(E) List special courses/training competed (PTD/DDC, Haz Mat, etc.)
(F) List any Safe Driving Awards you hold and from whom
(G) Accident Record for past three years

Date of AccidentNature of Accidents (Head on, rear end, upset, etc.)Location of Accident# of Fatalities# of People Injured

(H) Traffic Convictions and Forfeitures for the last three years (other than parking violations)

Date LocationChargePenalty

(I) Driver's License (list each driver's license held in the past three years)

StateLicense #TypeEndorsementsExpiration Date
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO
B. Has any license, permit or privilege ever been suspended or revoked? YES NO
C. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)? YES NO
D. Have you ever been convicted of a felony? YES NO
(J) If the answers to A, B, C or D is "YES", give details
Terms & Conditions
  • It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.
  • It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information.
  • It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.
  • I agree to furnish such additional information and complete such examinations as may be required to complete my application file.
  • It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant.
  • It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.
  • 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

THE ROAD MORE TRAVELED

Established in 1976, Laufer Trucking, Inc. has proven experience and a reputation for excellent customer service.

Laufer Trucking works hard to maintain a great safety record and to always have on time pick-ups and deliveries. We have a variety of equipment and are capable of everyday movements, as well as specialized shipments. Laufer Trucking's niche is maximizing full utilization of space on our trailers on a roundtrip and one-way basis. Laufer Trucking is also a dedicated in-house carrier.

THE FLEET

Vans

Step Deck (Curtain Side)

Curtain Side Flats

Flatbeds

Double Deck

CONTACT

955 Western Drive, Hartford WI 53027

Phone: (262) 673-6810

Toll Free: (800) 336-3296

Fax: (262) 673-6895

email: