Cimarron Drivers Application 
Must be completed by the Applicant 
Phone Number: 1-800-866-7713          Fax Number: 419-855-8398  
Any Line Marked With a * is Required 

  First name*                                       Middle*    Last name*
   
  Address*
 
 City*                                                                         State*                Zip*
   

 Daytime Phone*                                          Fax Number  
  
Email Address*
 

The U.S. Dept of Transportation requires that drive applicants state their date of birth.
Social Security #*       Birthdate*

  
Have you been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of a foot, leg, hand or arm?


Are you 23 years old or older?:
Can you speak English?:

Can you read English?:

Can you write English?:

Can you, upon offer of position, submit verification of your legal right to work in the U.S.?:
Position desired:
Contractors Name (if applicable):
Owners Tractor Info: YEAR:
MAKE:
Type of position:
Are you now employed?:
Date available to start work?:

Have you worked for Cimarron before?: 

If yes, give dates:

 to

























 

 

 

Have you ever been conficted of a felony?:           

If yes, explain-Indicate types of offense(s) involved, and date(s) of conviction(s), imprisonment(s), release(s) and rehabilitation(s):




Driving Experience 

Do you presently hold a valid CDL license?:*

State that issued the license?:*

License #:*

Date issed:*

Expires on date:*

Has your CDL ever been suspended or revoked?:

If yes, please explain:

During the preceding 3 years, have you had any traffic convictions? Please list date, location and name of court:



Experience:

Type of equipment?:
Number of years:

Approximate number of miles:

Tractor and trailer:

Other:

During the last 3 years, list any driving accidents you have had:



If you have not resided at the current address listed above for more than 3 years, list 3 year residence history here:
Address, City, State


 
Employment History 

The U.S. Department of Transportation requires that driver applicants show:
ALL EMPLOYMENT FOR THE PAST 10 YEARS

Recent Employer*

Name:*                                                                                                     From:*                    to*
   
City:*                                       State:*
  
Phone Number:*                      Position Held:*                                                     Pay Rate*
  
Reason for leaving:*

Former Employer #2

Name:*                                                                                                     From:*                    to*
   
City:*                                       State:*
  
Phone Number:*                      Position Held:*                                                     Pay Rate*
  
Reason for leaving:*

Former Employer #3

Name:*                                                                                                     From:*                    to*
   
City:*                                       State:*
  
Phone Number:*                      Position Held:*                                                     Pay Rate*
  
Reason for leaving:*

Former Employer #4

Name:*                                                                                                     From:*                    to*
   
City:*                                       State:*
  
Phone Number:*                      Position Held:*                                                     Pay Rate*
  
*Reason for leaving:

Former Employer #5

Name:*                                                                                                     From:*                    to*
   
City:*                                       State:*
  
Phone Number:*                      Position Held:*                                                     Pay Rate*
  
*Reason for leaving:

Former Employer #6

Name:*                                                                                                     From:*                    to*
   
City:*                                       State:*
  
Phone Number:*                      Position Held:*                                                     Pay Rate*
  
*Reason for leaving:

Former Employer #7

Name:*                                                                                                     From:*                    to*
   
City:*                                       State:*
  
Phone Number:*                      Position Held:*                                                     Pay Rate*
  
*Reason for leaving:

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS.

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your employment with Cimarron Express, Inc. ("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one of more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Administration (FMCSA).

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 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 FMCSA; that the FMCSA 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 you with 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 were the creased 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 Cimarron Express, Inc. ("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. I understand I may challenge the accuracy of the data by submitting a request to https://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 I 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.

THE SUBMISSION OF THIS APPLICATION VALIDATES MY SIGNATURE

Date:     Name:  

I Agree to the terms specified 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 law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA 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 my NOT be included with other consent forms or any other language.


DISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES

Disclosure

Cimarron Express, Inc. (the "Company") may request from a consumer reporting agency and for employment-related purposes, a "consumer report(s)" (commonly known as "background reports") containing background information about you in connection with your employment, or application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable).

HireRight, LLC ("HireRight") will prepare or assemble the background reports for the Company. HireRight is located and can be contacted at 3349 Michelson Drive, Suite 150, Irvine, CA 92612, (800) 400-2761, www.hireright.com.

The background report(s) may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. The types of background information that may be obtained include, but are not limited to: criminal history; litigation history; motor vehicle record and accident history; social security number verification; address and alias history; credit history; verification of your education, employment and earnings history; professional licensing, credential and certification checks; drug/alcohol testing results and history; military service; and other information.


Authorization

I hereby authorize Company to obtain the consumer reports described above about me.


THE SUBMISSION OF THIS APPLICATION VALIDATES MY SIGNATURE

Name:      Date: 

I Agree to the terms specified above.

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