KE Carriers, LLC Employment Application
Paper Application
First Name  
Middle Name  
Last Name  
Phone  
Email  
Date of Birth  
Social Security #  
Date Of Application  
Position Applied For  
Date Available For Work  
Do you have legal right to work in the United Sates? 
Current Address  
Current Mailing Address  
Previous Residency Address 
Previous Residency Address 
Previous Residency Address 
No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. 
Current License State  
Current License #  
Current License Type/Class 
Current License Endorsements 
Current License Expiration Date 
Previous License State  
Previous License #  
Previous License Type/Class 
Previous License Endorsements 
Previous License Expiration Date 
Previous License State  
Previous License #  
Previous License Type/Class 
Previous License Endorsements 
Previous License Expiration Date 
List Driving Experience for Straight Truck: Date From & To, Approx Mileage, & Equipment Type (Van, Tank, Flat, Etc.)  
List Driving Experience for Tractor & Semi-Trailer: Date From & To, Approx Mileage, & Equipment Type (Van, Tank, Flat, Etc.)  
List Driving Experience for Tractor & 2 Trailers: Date From & To, Approx Mileage, & Equipment Type (Van, Tank, Flat, Etc.)  
List Driving Experience for Tractor & Tank: Date From & To, Approx Mileage, & Equipment Type (Van, Tank, Flat, Etc.)  
List Driving Experience for Other: Date From & To, Approx Mileage, & Equipment Type (Van, Tank, Flat, Etc.)  
Accident Record for the Past 3 Years: Check this box if none  
Date of Accident  
Nature of Accident (Head-on, rear-end, upset, etc.) 
# of Fatalities  
# of Injuries  
Chemical Spills (Y/N)  
Date of Accident  
Nature of Accident (Head-on, rear-end, upset, etc.) 
# of Fatalities  
# of Injuries  
Chemical Spills (Y/N)  
Date of Accident  
Nature of Accident (Head-on, rear-end, upset, etc.) 
# of Fatalities  
# of Injuries  
Chemical Spills (Y/N)  
Traffic Convictions and Forfeitures for the Past 3 Years (Other Than Parking Violations: Check this box if none 
Date Convicted  
Violation  
State of Violation  
Penalty (Forfetied bond, collateral and/or points) 
Date Convicted  
Violation  
State of Violation  
Penalty (Forfetied bond, collateral and/or points) 
Date Convicted  
Violation  
State of Violation  
Penalty (Forfetied bond, collateral and/or points) 
Date Convicted  
Violation  
State of Violation  
Penalty (Forfetied bond, collateral and/or points) 
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?   Yes    No  
If yes, explain  
Has any license, permit, or privilege ever been suspended or revoked?   Yes    No  
If yes, explain  
Current (Most Recent) Employer Name 
Phone  
Address  
Position Held  
From  
To  
Reason for Leaving  
Salary  
Explain Any Gaps in Employment (Include month/year & reason)  
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?   Yes    No  
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substancestesting asrequired by 49 CFR, part 40?    Yes    No  
Second (Most Recent) Employer Name 
Phone  
Address  
Position Held  
From  
To  
Reason for Leaving  
Salary  
Explain Any Gaps in Employment (Include month/year & reason)  
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?   Yes    No  
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substancestesting asrequired by 49 CFR, part 40?    Yes    No  
Third (Most Recent) Employer Name 
Phone  
Address  
Position Held  
From  
To  
Reason for Leaving  
Salary  
Explain Any Gaps in Employment (Include month/year & reason)  
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?   Yes    No  
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substancestesting asrequired by 49 CFR, part 40?    Yes    No  
High School Name  
Course of Study  
Years Completed  
Graduate    Yes
 No
Details  
College Name  
Course of Study  
Years Completed  
Graduate    Yes
 No
Details  
Other Education Name  
Course of Study  
Years Completed  
Graduate    Yes
 No
Details  
Please list any other qualificationsthat you have and which you believe should be considered.  
I have read the information at the bottom of this form and agree 
Please type the text in the box.


   
  

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to:

• Review information provided by current/previous employers;
• Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; and
• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.
 
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