Please enable JavaScript in your browser to complete this form. - Step 1 of 6General Information Please complete the form below.What position are you applying for? *Please SelectSoutheast RegionalFlorida OnlyLocal (Jacksonville, FL)Full Name *FirstLastEmail *PhoneAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHave you been at this address for 3 or more years? *Please Select Yes or NoYesNoPrevious Addresses Date of Birth *Social Security NumberHave you ever been known by any other name? *Yes or No?YesNoPlease List Name(s)If hired, can you furnish proof you are eligible to work in the United States? *Please SelectYesNoAre you at least 23 years of age or older?Please SelectYesNoHave you held a VALID US license for the past 36 months? *Please SelectYesNoLicense Class *Please SelectClass-AClass-BThird ChoiceDrivers License Number *State of Issue *Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense Expiration Date *Expiration Date of DOT Physical CardNextCDL Information Please complete the form below.CDL Endorsements *NoneTankerDoubles/TriplesHazmatX EndorsementTWICHazmat ExpirationTWIC Expiration DatePlease list any licenses held in other states for the previous 5 years, include license numbers if you can.Have you been to truck driving school? *Please SelectYesNoSchool NameSchool PhoneSchool AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeGPA if availableNextCurrent/Previous Employer Please complete the form below. Start Date *Ending Date *Employer Name *Employer AddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateEmployer Phone *Position Held *Reason for Leaving *Is this your current employer? *Please SelectYesNoMay we contact this employer at this time? *Please SelectYesNoWas this a driving position? *Please SelectYesNoType of Truck(s) *Day CabConventional SleeperStraight TruckBox TruckDump TruckMixerType of Trailer(s) *VanFlatbedRefferTankerRGN LowboyTrailer Length(s) *24' - 38'38 - 44'45 - 53'NextPrevious Employer Please list current or most recent first. Start Date #2Ending Date #2Employer Name #2Employer Address #2Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateEmployer Phone #2Position Held #2Reason for Leaving #2May we contact this employer at this time? #2Please SelectYesNoWas this a driving position? #2Please SelectYesNoType of Truck(s) #2Day CabConventional SleeperStraight TruckBox TruckDump TruckMixerType of Trailer(s) #2VanFlatbedRefferTankerRGN LowboyTrailer Length(s) #224' - 38'38 - 44'45 - 53'NextAdditional Information Please answer the following questions.Have you had any moving violations in the last 5 years? *Please SelectYesNoPlease list City, County and State, month, year and nature of offense and any fines involved. Please list miles over limit for speeding.Has your license ever been suspended? *Please SelectYesNoPlease give date and length of supension. List reason why, city, county and state.Have you had any accidents in the last 5 years? *Please SelectYesNoPlease give date, explaination, city, county and state and if you received ticket/fine (amount).Have you ever had a DUI, DWI, or OVI? *Please SelectYesNoPlease list date of offense, jail time, fine and or suspension time. We must have complete information to satisfy isusance carrier requirements. Have you ever been convicted of a felony? *Please SelectYesNoPlease give date and nature of offense, city, county, state and any fines and time served Please list EVERYTHING asked for per isurance requirements.Have you ever been convicted of a misdemeanor? *Please SelectYesNoPlease list date and nature of offense, city, county and state. also jail time, probation, or fines Please list EVERYTHING asked for.References References: Please list name, address, phone and years known.Reference Name Reference PhoneReference Address Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextAgree to Information Request *I grant Atlantic Truck Lines permission to request any and all personal information from my previous employers, to access DAC, and to search by any other reasonable means to verify my background. I certify this information to be true and correct.Agree to Employer Check *I agree Previous Employer CheckPSP Document *I AgreeIMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with Atlantic Truck Lines ("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 (FM CSA). 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 ยท 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 FM CSA; that the FM CSA 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 If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize Atlantic Truck Lines ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am 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. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. I 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. 1 understand I may challenge the accuracy of the data by submitting a request to https:1/dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where 1 was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I 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 Jaw to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FM CSA 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. LAST UP DA TED 12/22/2015 Signature *Clear SignatureMessageSubmit