Billy Barnes Enterprises, Inc.

Contact Information
*Full Name:
*Address 1:
 Address 2:
*City: *State: ---AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming *Zip:
*Day Phone: Cell Phone:
 Email: Best Time to Call:
*SSN: *Date of Birth: *Age:

CDL Information
Do you have a CDL?  Yes No     CDL Number:
Issue State: ---AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming Expiration Date:
Previous Number:
Previous Issue State: ---AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming Class A?  Yes No

Driver Information
For which position are you applying for?  Local Regional
Total OTR Years: none1 mo.2 mo.3 mo.4 mo.5 mo.6 mo.7 mo.8 mo.9 mo.10 mo.11 mo.12 mo.13 mo.14 mo.15 mo.16 mo.17 mo.18 mo.19 mo.20 mo.21 mo.22 mo.23 mo.24 mo.3 yrs.4 yrs.5 yrs.6 yrs.7 yrs.8 yrs.9 yrs.10 yrs.11 yrs.12 yrs.13 yrs.14 yrs.15 yrs.16 yrs.17 yrs.18 yrs.19 yrs.20+ yrs.
Do you have at least 1 year of verifiable OTR experience?  Yes No
Have you graduated from a certified trucking school?  Yes No

Trailer Type Experience and Preference
Flatbed Experience:  Yes No      Years: none1 mo.2 mo.3 mo.4 mo.5 mo.6 mo.7 mo.8 mo.9 mo.10 mo.11 mo.12 mo.13 mo.14 mo.15 mo.16 mo.17 mo.18 mo.19 mo.20 mo.21 mo.22 mo.23 mo.24 mo.3 yrs.4 yrs.5 yrs.6 yrs.7 yrs.8 yrs.9 yrs.10 yrs.11 yrs.12 yrs.13 yrs.14 yrs.15 yrs.16 yrs.17 yrs.18 yrs.19 yrs.20+ yrs.
Materials Hauled
Steel Coils:  Yes No
Flat Steel:  Yes No
Pipe:  Yes No
Building Materials:  Yes No
States
In which states have you operated in the past 5 years?

Regional Driving Preferences
Check all that apply:
 North Central South Central North East South East South West  Local

Current Employer
Employer Name:
Address: Phone:
City: State: ---AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming Zip:
Start Date:
Position Held: Pay Rate:
Supervisor:  You may contact this employer
Vehicle Driven:
Were you subject to FMCSR's?  Yes No
Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing required by 49 CFR part 40?  Yes No

Previous Employer #1
Employer Name:
Address: Phone:
City: State: ---AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming Zip:
Start Date: End Date:
Position Held: Pay Rate:
Supervisor:  You may contact this employer
Reason Left:
Vehicle Driven:
Were you subject to FMCSR's?  Yes No
Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing required by 49 CFR part 40?  Yes No

Previous Employer #2
Employer Name:
Address: Phone:
City: State: ---AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming Zip:
Start Date: End Date:
Position Held: Pay Rate:
Supervisor:  You may contact this employer
Reason Left:
Vehicle Driven:
Were you subject to FMCSR's?  Yes No
Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing required by 49 CFR part 40?  Yes No

Previous Employer #3
Employer Name:
Address: Phone:
City: State: ---AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming Zip:
Start Date: End Date:
Position Held: Pay Rate:
Supervisor:  You may contact this employer
Reason Left:
Vehicle Driven:
Were you subject to FMCSR's?  Yes No
Was job designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing required by 49 CFR part 40?  Yes No

Additional Employment Information

Accidents
Number of Accidents Involved:
Number of Preventable Accidents:
Number of Roll-Over Accidents:

Tickets
Number of Tickets Received:
Number of Preventable Tickets:
Number of Reckless Tickets:

Addition Driving History Information

Criminal Record
Are you a US citizen?
 Yes No
If no, do you have a legal right to live and work in the US?
 Yes No
Have you ever been convicted of a felony?
 Yes No
If so, please explain

Have you ever been convicted, or are any charges pending, for driving while under the influence of alcohol, a narcotic drug, amphetamines or derivatives thereof?
 Yes No
Have you ever been convicted of a crime or have any charges pending?
 Yes No
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
 Yes No
Has any license, permit or privilege ever been suspended or revoked?
 Yes No
Have you ever been refused any type of insurance or been denied bonding?
 Yes No
Have you ever tested positive or refused a test for drugs or alcohol?
 Yes No
Have you ever abandoned your equipment?
 Yes No
Have you ever been disqualified for violations of the Federal Motor Safety Regulations?
 Yes No

Agreement
I hereby certify that all information on this form is correct and complete to the best of my knowledge. I hereby authorize Billy Barnes Enterprises, Inc.,. 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 substances testing and training records 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 Billy Barnes Enterprises, Inc. or its subsidiaries in their consideration of my employment.

I understand that I have the right to review information provided by previous employers, have errors corrected by previous employer and resubmitted to Impact and/or have a rebuttal statement attached to erroneous information if my previous employer and I cannot agree on the accuracy of the information. I understand that I must request past employer information obtained by Billy Barnes Enterprises, Inc.in writing within 30-days of employment or denial of employment.

I have read and agree to the above release and I give permission to obtain consumer reports about me from DAC.  Yes No