Text Box: Driver Application of Employment Applying for : Solo ____ Team____with________________ Owner/Operator ______ Model/year:___________ Marten Transport Ltd. 129 Marten Street Mondovi, WI 54755 General Information Name: Last_________________________________ First______________________________ Middle______________ Former Name:______________________ Social Security #:________ - _____ -__________ Birth Date:____/___/_____ Home Phone: ( _________ ) _________ - __________ Contact Phone ( _________ ) ___________ - _____________ Current Address:___________________________________City___________________ State______ Zip____________ Past Address if less than 3 years at present: ______________________________________________________________ City ___________________________ State _________ Zip ____________ Regions driven in: qNW qSW qNE qSE qMidwest qCanada Have you ever been convicted of/or have a pending felony? qYes qNo If yes, when?__________ Have you ever been convicted of/or have a pending DWI/DUI? qYes qNo If yes, when?__________ Have you tested positive or refused to test for alcohol/controlled substances in the last 3 years? qYes qNo If yes, when?__________ Have you tested positive or refused to test on a pre-employment alcohol/controlled substances in the last 3 years? qYes qNo If yes, when?__________ Are you authorized to work in the United States under federal law? qYes qNo Are you able to pass a two year DOT physical? qYes qNo Has your license ever been denied, revoked or suspended? qYes qNo If yes, when?__________ (Please explain any denial, revocation or suspension in the Traffic Violations area) How were you referred to Marten? ____________________ Driver? qYes qNo Name?_______________ Have you ever q worked / applied q with us before? qYes qNo If yes, when?__________ Driver’s License Information List all unexpired licenses you currently hold: State License Number Class Endorsements Expiration Date 1._______________________________________________________________________________________/_____/____ 2. _______________________________________________________________________________________/_____/____ 3. _______________________________________________________________________________________/_____/____ Traffic Violations (last 3 years) Date State Type of Violation (i.e. speeding - 10 miles over) Points or Penalty ___/___/___ ______ _______________________________________________ _____________________ ___/___/___ ______ _______________________________________________ _____________________ ___/___/___ ______ _______________________________________________ _____________________ ___/___/___ ______ _______________________________________________ _____________________ Accident Information (last 3 years) Date Vehicle Nature of Accident Non Preventable Injuries Fatalities Amount Or Preventable ___/___/__ _________ _______________________________ ______________ ________ _______ __________ ___/___/__ _________ _______________________________ ______________ ________ _______ __________ ___/___/__ _________ _______________________________ ______________ ________ _______ __________ ___/___/__ _________ _______________________________ ______________ ________ _______ __________ Experience/Education Months of Over-the-Road Experience in the last five years _________________ Driving school attended (if less than 12 months of experience):________________________________________________ Driving school phone # (________)__________________ City: __________________________ State: ______________ Graduation Date:_____________ Employment History In compliance with CFR 49 parts 391.21 (b(11) a complete record of employment for the past ten years is necessary for your application to be processed. Please list your present employer first. All periods of time must be accounted for during this ten-year period, including military service, self-employment, non-driving positions and periods of unemployment. Provide complete address and phone numbers, including area codes and zip codes. From:__________To:__________ Company Name:__________________________________________________________ Phone:( ______ ) _____________ Street Address:___________________________________________________________ Position:____________________ City:___________________________________State:_______________Zip:_________ Type of Equipment Operated:_____________________________________________ Ending Pay: __________________ Were you subject to FMCSR’s?  Yes  No Was your job designated as a Safety Sensitive Function?  Yes  No Reason For Leaving:______________________________________________________ From:__________To:__________ Company Name:__________________________________________________________ Phone:( ______ ) _____________ Street Address:___________________________________________________________ Position:____________________ City:___________________________________State:_______________Zip:_________ Type of Equipment Operated:_____________________________________________ Ending Pay: __________________ Were you subject to FMCSR’s?  Yes  No Was your job designated as a Safety Sensitive Function?  Yes  No Reason For Leaving:______________________________________________________ From:__________To:__________ Company Name:__________________________________________________________ Phone:( ______ ) _____________ Street Address:___________________________________________________________ Position:____________________ City:___________________________________State:_______________Zip:_________ Type of Equipment Operated:_____________________________________________ Ending Pay: __________________ Were you subject to FMCSR’s?  Yes  No Was your job designated as a Safety Sensitive Function?  Yes  No Reason For Leaving:______________________________________________________ From:__________To:__________ Company Name:__________________________________________________________ Phone:( ______ ) _____________ Street Address:___________________________________________________________ Position:____________________ City:___________________________________State:_______________Zip:_________ Type of Equipment Operated:_____________________________________________ Ending Pay: __________________ Were you subject to FMCSR’s?  Yes  No Was your job designated as a Safety Sensitive Function?  Yes  No Reason For Leaving:______________________________________________________ From:__________To:__________ Company Name:__________________________________________________________ Phone:( ______ ) _____________ Street Address:___________________________________________________________ Position:____________________ City:___________________________________State:_______________Zip:_________ Type of Equipment Operated:_____________________________________________ Ending Pay: __________________ Were you subject to FMCSR’s?  Yes  No Was your job designated as a Safety Sensitive Function?  Yes  No Reason For Leaving:______________________________________________________ From:__________To:__________ Company Name:__________________________________________________________ Phone:( ______ ) _____________ Street Address:___________________________________________________________ Position:____________________ City:___________________________________State:_______________Zip:_________ Type of Equipment Operated:_____________________________________________ Ending Pay: __________________ Were you subject to FMCSR’s?  Yes  No Was your job designated as a Safety Sensitive Function?  Yes  No Reason For Leaving:______________________________________________________ From:__________To:__________ Company Name:__________________________________________________________ Phone:( ______ ) _____________ Street Address:___________________________________________________________ Position:____________________ City:___________________________________State:_______________Zip:_________ Type of Equipment Operated:_____________________________________________ Ending Pay: __________________ Were you subject to FMCSR’s?  Yes  No Was your job designated as a Safety Sensitive Function?  Yes  No Reason For Leaving:______________________________________________________ Employment History Continued From:__________To:__________ Company Name:__________________________________________________________ Phone:( ______ ) _____________ Street Address:___________________________________________________________ Position:____________________ City:___________________________________State:_______________Zip:_________ Type of Equipment Operated:_____________________________________________ Ending Pay: __________________ Were you subject to FMCSR’s?  Yes  No Was your job designated as a Safety Sensitive Function?  Yes  No Reason For Leaving:______________________________________________________ From:__________To:__________ Company Name:__________________________________________________________ Phone:( ______ ) _____________ Street Address:___________________________________________________________ Position:____________________ City:___________________________________State:_______________Zip:_________ Type of Equipment Operated:_____________________________________________ Ending Pay: __________________ Were you subject to FMCSR’s?  Yes  No Was your job designated as a Safety Sensitive Function?  Yes  No Reason For Leaving:______________________________________________________ In case of emergency: _______________________ ______________________ ___________________________________ ( ___)___________ Name Relationship City, State Phone Number _______________________ ______________________ ___________________________________ ( ___)___________ Name Relationship City, State Phone Number We appreciate your interest in Marten Transport, Ltd. I hereby certify that all information on this application was completed by me and is true and complete to the best of my knowledge. I understand that any omission or misrepresentation is “falsification” and may result in refusal of or separation from employment. I hereby authorize Marten Transport Ltd. to do a complete background investigation in accordance with state and federal laws. I authorize release of any information, including all information related to my alcohol and controlled substance testing and training records as required by the Federal Highway Administration (FHWA) 49 CFR Parts 391 or 382, by any past or current employers. I hereby release all such persons from any liability or damages. I consent to the procurement and use of any consumer reports, including reports from DAC Services, Inc., deemed necessary by Marten Transport Ltd. in their consideration of my employment. I understand it is my right to review and contest any information received from my previous employers. ________________________________________________________ __________________________________ Signature Date /srd 10/04 We are an Equal Employment Opportunity Employer. No question is asked for the purpose of excluding any applicant due to race, creed, color, national origin, religion, age, sex, handicap or disability, veteran status, or any other class of individuals protected by law. This application will be current for only three months. If you have not heard from Marten Transport Ltd. and still wish to be considered for employment at the end of the three months, you must fill out a new application.