Intercity Lines Driver Application


Intercity Lines, Inc.
P.O. Box 1299 Warren MA 01083
APPLICATION FOR EMPLOYMENT

Name (First,Middle,Last):  

Date:

Current Address (Street, City, State, & Zip Code):   

How long have you been living at the above address?:  

Phone Number:  

Email:  

Previous Address (Past 3 Years):  

How long did you live there:  

Previous Address 2: (Past 3 Years):  

How long did you live there:  

Emergency Contact Name:

Emergency Contact Phone Number:  


Licensing: 

State Licensed:  

License Number:  

License Type:  

License Expiration Date:  


EXPERIENCE AND QUALIFICATIONS DRIVING EXPERIENCE:

1.Class of Equipment:  

Type of Equipment:  

Date from:  

Date to:  

Miles Driven:  


2.Class of Equipment:  

Type of Equipment:  

Date from:  

Date to:  

Miles Driven:  


3.Class of Equipment:  

Type of Equipment:  

Date from:  

Date to:  

Miles Driven:  


4.Class of Equipment:  

Type of Equipment:  

Date from:  

Date to:  

Miles Driven:  

Additional employment or information for the last 10 years:

ACCIDENT RECORD FOR PREVIOUS 3 YEARS

1. Dates:  

Nature of Accident:  

Injuries:  

Fatalities:  


2. Dates:  

Nature of Accident:  

Injuries:  

Fatalities:  


3. Dates:  

Nature of Accident:  

Injuries:  

Fatalities:  


4. Dates:  

Nature of Accident:  

Injuries:  

Fatalities:  


TRAFFIC CONVICTIONS AND FORFEITURES FOR PREVIOUS 3 YEARS (OTHER THAN PARKING)

1. Location:  

Date:  

Charge:  

Penalty:  


2. Location:  

Date:  

Charge:  

Penalty:  


3. Location:  

Date:  

Charge:  

Penalty:  


4. Location:  

Date:  

Charge:  

Penalty:  


A.  HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE?:  

B.HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED?  

(IF THE ANSWER TO EITHER A ORB IS YES, ATTACH ADDITIONAL STATEMENT GIVING DETAILS)

EDUCATION:

Highest Grade Completed:  

College:  

Last School attended:  

Intercity Lines, Inc.
P.O. Box 1299 Warren MA 01083

APPLICANT: AS REQUIRED BY THE US DOT, THE INFORMATION PROVIDED ON THIS PAGE PERTAINING TO PREVIOUS EMPLOYMENT HISTORY MAY BE USED AND YOUR PREVIOUS EMPLOYERS WILL BE CONTACTED FOR THE PURPOSE OF INVESTIGATING YOUR SAFETY PERFORMANCE HISTORY. UNDER DOT REGULATIONS, YOU HAVE THE RIGHT TO
REVIEW AND REBUT INFORMATION PROVIDED BY A PREVIOUS EMPLOYER. APPLICANTS WISHING TO REVIEW
PREVIOUS EMPLOYER-PROVIDED INVESTIGATIVE INFORMATION MUST SUBMIT A WRITTEN REQUEST TO THE
PROSPECTIVE EMPLOYER. PLEASE SEE THE PROSPECTIVE EMPLOYER AND THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS FOR YOUR SPECIFIC RIGHTS UNDER THIS US DOT REGULATION 391.23.

Employment Record:

NOTE: DOT Requires that Employment for at least 3 Years and / or Commercial Driving Experience for the past 1 O years be listed.

Last Employer:

Name:  

Phone #:  

Fax #:  

Address:

Street:  

City:  

State:  

ZIP:  

Position Held:  

From:

To:

Salary:  

Reason for Leaving:  

Were you subject to the DOT safety Rules?  

Subject to the DOT substance testing rules?  


2nd Last Employer:

Name:  

Phone #:  

Fax #:  

Address:

Street:  

City:  

State:  

ZIP:  

Position Held:  

From:

To:

Salary:  

Reason for Leaving:  

Were you subject to the DOT safety Rules?  

Subject to the DOT substance testing rules?  


3rd Last Employer:

Name:  

Phone #:  

Fax #:  

Address:

Street:  

City:  

State:  

ZIP:  

Position Held:  

From:

To:

Salary:  

Reason for Leaving:  

Were you subject to the DOT safety Rules?  

Subject to the DOT substance testing rules?  


4th Last Employer:

Name:  

Phone #:  

Fax #:  

Address:

Street:  

City:  

State:  

ZIP:  

Position Held:  

From:

To:

Salary:  

Reason for Leaving:  

Were you subject to the DOT safety Rules?  

Subject to the DOT substance testing rules?  


TO BE READ AND SIGNED BY THE APPLICANT
I hereby declare that the information provided by me in this Application for Employment is true, correct and complete to the best of my knowledge. I authorize Intercity Lines, Inc. to investigate my past and present
employment, education and activities and verify all data provided by me on this application, on related papers and in interviews. I authorize all individuals, schools and/or firms named herein (except my current employer, if so noted) to provide any information requested about me. I release from all liability any persons, companies, corporations or educational institutions supplying such information. I release Intercity Lines, Inc. from any and all liability resulting from the verification of such information. I understand that any false statement or
omission of fact on this application or on any supporting documents shall be grounds for non-hire or
discharge, regardless of when discovered by Intercity Lines, Inc.

Leave this empty:

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Signature Certificate
Document name: Intercity Lines Driver Application
lock iconUnique Document ID: 25ee6c5ffb9544eca339a1491116a0a0dbe49a74
TimestampAudit
February 11, 2020 9:35 am EDTIntercity Lines Driver Application Uploaded by NoReply IntercityLines - sharon@intercitylines.com IP 50.250.58.137, 185.93.229.11
February 21, 2020 11:55 am EDTdean wilson - dean@intercitylines.com added by NoReply IntercityLines - sharon@intercitylines.com as a CC'd Recipient Ip: 50.250.58.137, 185.93.229.11
February 21, 2020 11:55 am EDTdean gmail - deanwilson012@gmail.com added by NoReply IntercityLines - sharon@intercitylines.com as a CC'd Recipient Ip: 50.250.58.137, 185.93.229.11
February 21, 2020 11:55 am EDTbrady lorange - brady@intercitylines.com added by NoReply IntercityLines - sharon@intercitylines.com as a CC'd Recipient Ip: 50.250.58.137, 185.93.229.11
February 21, 2020 12:01 pm EDTdean wilson - dean@intercitylines.com added by NoReply IntercityLines - sharon@intercitylines.com as a CC'd Recipient Ip: 50.250.58.137, 185.93.229.11
February 21, 2020 12:01 pm EDTdean gmail - deanwilson012@gmail.com added by NoReply IntercityLines - sharon@intercitylines.com as a CC'd Recipient Ip: 50.250.58.137, 185.93.229.11
February 21, 2020 12:01 pm EDTbrady lorange - brady@intercitylines.com added by NoReply IntercityLines - sharon@intercitylines.com as a CC'd Recipient Ip: 50.250.58.137, 185.93.229.11