APPLICATION FORM

West Wind
5125 West Lake Street
Chicago, Illinois 60644

In compliane with Federal and State equal employment opportunities laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

PLEASE READ THE MESSAGE BELOW

I authorize you to make such investigations and inquireis of my personal, employment, financial or medial history and other related matters as may be necessary in arriving at an employmnet decision. (Generally, inquireis regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other personal 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 understand, also, that I am required to abide by all rules and regulations of the Company. I understand that information I provide regbarding current and/or previous 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(d) and (e). I understand that I have the right to: - Review informatioun provided by previous employers; - Have errors in the information corrected by previouse employers and for those previouse employers to re-send the corrected informatioun to the prospective employer; and - Have a rebuttal statement attached to the alleged erroneous informatioun, if the previous employer(s) and I cannnot agree on the accuracy of the information.

I accept I don't accept

Do you have your own company?
Yes No

THE COMPANY"S RECORD


Attachment: Copy of Internal Revenue Service (IRS)

APPLICANT TO COMPLETE

Please fill out all of the boxes.



CURRENT ADDRESS*

*Please list your addresses for the past 3 years.

PAST ADDRESSES



Do you have the legal rights to work in the United States?
Yes No


Have you worked for West Wind before?
Yes No


Dates:



Are you now employed?
Yes No



Have you ever been bonded?
Yes No



Have you ever been convicted of a felony?
Yes No

*If yes, please explain fully below. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.


Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the attached job description)?
Yes No

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

EMPLOYER

Dates:



Were you subject to the FMCRs^ While Employed?
Yes No


Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to teh drug and alcohol testing requirements of 49 CFR Part 40?
Yes No


EMPLOYER


Dates:



Were you subject to the FMCRs^ While Employed?
Yes No


Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to teh drug and alcohol testing requirements of 49 CFR Part 40?
Yes No


EMPLOYER


Dates:



Were you subject to the FMCRs^ While Employed?
Yes No


Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to teh drug and alcohol testing requirements of 49 CFR Part 40?
Yes No


EMPLOYER


Dates:



Were you subject to the FMCRs^ While Employed?
Yes No


Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to teh drug and alcohol testing requirements of 49 CFR Part 40?
Yes No


EMPLOYER


Dates:



Were you subject to the FMCRs^ While Employed?
Yes No


Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to teh drug and alcohol testing requirements of 49 CFR Part 40?
Yes No


*Includes vehicles having GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in the quantity requiring placarding.

^The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,0001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

ACCIDENT RECORD for past 3 or more years

Last Accident

Previous Accident

Previous Accident


TRAFFIC CONVICTIONS and forfeitures for the past 3 years (other than parking violations).







EXPERIENCE AND QUALIFICATIONS - DRIVER

List all driver licenses or permits held in the past 3 years




A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes No


B. Has any license, permit or privilege ever bee suspended or revoked?
Yes No


IF THE ANSWER IS TO EITHER A OR B IS YES, GIVE DETAILS


DRIVING EXPERIENCE (check yes or no)
Class of Equipment:
Straight Truck
Yes No


Tractor and Semi-Trailer
Yes No


Tractor - Three Trailers
Yes No


Tractor - Two Trailers
Yes No


Motorcoach - School Bus (More than 8 passengers)
Yes No


Motorcoach - School Bus Yes No More than 15 passengers
Yes No




List states operated in for last five years:


Which safe driving awards do you hold and from whom?


EXPERIENCE AND QUALIFICATIONS - OTHER
Show any tricking, transportation or other experience that may help in your work for this company


List courses and training other than shown elsewhere in the application


List special equipment or technical materials you can work with (other than already shown)


EDUCATION



IMPORTANT NOTICE


TO BE READ AND CONFIRMED BY APPLICANT



This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

1. In connection with your application for employment with West Wind, Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety 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 to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
2. I authorize West Wind 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 consenting to 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.
3. 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 am challenging 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.
4. Please note: 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 where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, 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.
I accept I don't accept
Contact form submitted.