1820 CR 423, Henderson, TX 75652

Phone: 903.722.9014
Fax: 903.722.9017

Driver Information Required:

Signed W-4
Signed I-9
Color Copy of Drivers License (Front & Back)
Copy of Social Security Card
Copy of LONG Medical Form

1820 CR 423, Henderson, TX 75652

Phone: 903.722.9014 Fax:

903.722.9017

DRIVER APPLICATION
Position Applied for: Driver Owner/Operator Driver for Owner/Operator

GENERAL INFORMATION
Full Name:

____________________________________________

Present Address:
Street________________________City________________State _______zip_______
If at present address for less than three years, list additional addresses for last three years:
Street
Street

City
City

Social Security #:
Drivers License #:
Class: A B C

State
State
Date of Birth:
State:

How Long?

Zip
Zip

How Long?
Phone #:

Endorsements:

CDL? Yes No

EDUCATION AND SKILLS

High School
____________________________ City __________________ State ______ Graduated?
Yes No College/Trade School _______________________ City __________________ State
______ Graduated? Yes No Driving School ____________________________ City
__________________ State ______ Graduated? Yes No
Have you ever been convicted of a felony? Yes No
If yes, please explain.
________________________________________________________________________________
________________________________________________________________________________
Have you ever been convicted of/or have a pending DWI/DUI? Yes No
If yes, where? ______________ Are you authorized to work in the United States? Yes No

COMMERCIAL DRIVERS LICENSE INFORMATION

List each drivers license held in the past 3 years. List the issuing state, number and
expiration date of each unexpired commercial motor vehicle operators license or
permit that has been issued to you.
State
License Number
Type
Endorsements
Expiration Date

DRIVING EXPERIENCE
List each type of commercial motor vehicle you have operated and for how long.

Class of Equipment
Straight Truck
Tractor & Semi
Trailer
Tractor- 2 Trailers

Types of Equipment
(Van, Flatbed, Tanker,
etc.)

From

To

Approximate Miles

Other

List other relevant experience:____________________________________________________________

Please list any safe driving awards you have received:__________________________________________
List all states operated in the last 5 years ____________________________________________________

DRIVER PAST RECORD

1. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes
No
2. Have you ever been disqualified for violations(s) of the FMCSR?
Yes
No
3. Has any license, permit or privilege ever been suspended or revoked?
Yes
No
If yes to any of the above questions, describe: ________________________________________
_____________________________________________________________________________

ACCIDENT AND INCIDENT

Accident record for the past 3 years (attach sheet if more space is needed). List each vehicle accident or
any incident regarding damage to a vehicle or personal property in which you were involved during the
past three years preceding the date of this application.
Dates of Accident and
Type of Vehicle

Nature of Accident
(Head-on, Rear-End, etc.)

Location of
Accident

# of
Fatalities

# of Injuries

Traffic convictions and forfeitures for the past 3 years (other than parking violations) of which you were
convicted, forfeited bond or collateral during the three years preceding the date of this application.
Location
Date
Charge
Penalty

EMPLOYMENT INFORMATION
List all periods of employment and unemployment, starting with the most recent. CFR 391.51(b)
requires three years of history to be verified and 7 subsequent years to be recorded for a total of 10 years
of employment history, or to the extent of which the applicant has worked.
Employer Name:________________________________ Telephone #:__________________
Fax:_________________
Address:

Position:

____________________________

Street

City

State

Zip
Supervisor Name:

Employed From:

to

/_____

Ending Salary: $____________________

Reason for
Leaving:____________________________________________________________________________
___
CDL Required? Yes No Were you subject to the FMCSR while Employed?
Yes No Was the job designated as a safety sensitive function? Yes No
If gap between employers, indicate reason: Unemployed School Self Employed Other:

Employer Name:________________________________ Telephone #:__________________

Fax:_________________
Address:

Position:

____________________________
Supervisor Name:

Street

City
Employed From:

State
/

to

Zip
/_____

Ending Salary: $____________________

Reason for
Leaving:______________________________________________________________________________
_
CDL Required? Yes No Were you subject to the FMCSR while Employed?
Yes No Was the job designated as a safety sensitive function? Yes No
If gap between employers, indicate reason: Unemployed School Self Employed Other:

Employer Name:________________________________ Telephone #:__________________

Fax_________________
Address:

Position:

____________________________

Street

City

State

Zip
Supervisor Name:

Employed From:

to

/_____

Ending Salary: $____________________

Reason for
Leaving:____________________________________________________________________________
___
CDL Required? Yes No Were you subject to the FMCSR while Employed?
Yes No Was the job designated as a safety sensitive function? Yes No
If gap between employers, indicate reason: Unemployed School Self Employed Other:
Employer Name:________________________________ Telephone #:__________________ Fax
_________________
Address:

Position:

____________________________

Street

Supervisor Name:

City

State

Employed From:

to

Zip
/_____

Ending Salary: $____________________

Reason for
Leaving:_____________________________________________________________________________
__
CDL Required? Yes No Were you subject to the FMCSR while Employed?
Yes No Was the job designated as a safety sensitive function? Yes No
If gap between employers, indicate reason: Unemployed School Self Employed Other:
Employer Name:_________________________________ Telephone #:__________________
Fax:________________
Address:

Position:

____________________________

Street

City

State

Zip
Supervisor Name:

Employed From:

to

/_____

Ending Salary: $____________________

Reason for
Leaving:____________________________________________________________________________
___
CDL Required? Yes No Were you subject to the FMCSR while Employed?
Yes No Was the job designated as a safety sensitive function? Yes No
If gap between employers, indicate reason: Unemployed School Self Employed Other:

Employer Name:________________________________ Telephone #:__________________

Fax:_________________
Address:

Position:

____________________________

Street

City

State

Zip
Supervisor Name:

Employed From:

to

/_____

Ending Salary: $____________________

Reason for
Leaving:_________________________________________________________________________
______
CDL Required? Yes No Were you subject to the FMCSR while Employed?
Yes No Was the job designated as a safety sensitive function? Yes No
If gap between employers, indicate reason: Unemployed School Self Employed Other:

Emergency Contact Information

Please List at least 2 Emergency contacts.

Contact Name: _________________________

Phone Number: ________________________
Email: ________________________________

Contact Name: _________________________

Phone Number: ________________________
Email: ________________________________

Contact Name: _________________________

Phone Number: ________________________
Email: ________________________________

APPLICANT CERTIFICATION

By signing this statement, I certify that:

1. This application for employment was completed by me and that all entries on it and the information contained
within it are true and correct to the best of my knowledge.
2. As required by section 383.21 of the FMCSR, I only have one motor vehicle operators license.
Furthermore, I authorize TruCore Energy, LLC to make such investigations and inquiries of my personal,
employment, financial or medical history and other related matters as may be necessary in arriving at the
employment decision. I hereby release any and all of the employers, schools, health care providers, company and
any subsidiaries, as well as any other persons associated with this application for employment and the subsequent
processes and procedures from all liability in response to inquiries and releasing of information given in my
application or interview(s). Failure to answer application or interview questions honestly, fully, and to the best of
my knowledge may be considered fraud and could be construed as criminal, and may be grounds for termination and
permanent discharge from this company. I understand that I am required to abide by all rules and regulations of the
company as outlined in the company policies and statements.
I understand that information that I provide regarding 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 I have the right to:
a. Review information provided by previous employers;
b. Have errors in the information corrected by previous employers and for those previous employers to resend the
corrected information to the prospective employer; and
c. 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.
d. Any employee that does not make the 90 day probation period for any reason will be charged back the cost of the
physical and drug screen charges of $200.00, plus any issued equipment that has not been returned. Owner
Operators will be charged back for the physical and drug screen.

Applicants Signature:

Date:

TruCore Energy LLC is an equal opportunity employer TruCore Energy LLC does not discriminate on the basis of race, color, religion, gender,
age, sexual orientation, national origin or ancestry, physical or mental disability, marital status, pregnancy, veteran status, medical condition, or
any other protected status as defined by law.

FOR OFFICE USE ONLY DON NOT WRITE IN THIS SPACE

Applicant Hired? Yes No

Date Hired:
TERMINATION INFORMATION

Date Terminated:
Reason for Termination: Dismissed
Voluntary Separation
Other:

FAIR CREDIT REPORTING ACT

DISCLOSURE STATEMENT
In accordance with the provisions of Section 604(b) (2) (A) of the Fair Credit Reporting Act, Public Law
91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of
Public Law 104-208), you are being informed that reports verifying your previous employment, previous
drug and alcohol test results, and driving record may be obtained for employment purposes. Sections
382.413, 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations, require these reports.
APPLICANT:
Signature:
Date:
Print Name: __________________________ SSN#:_________________________________________
Company Name: TruCore Energy, LLC

CONSENT TO PRE-EMPLOYMENT DRUG/ALCOHOL TESTING

I understand it is the policy of TruCore Energy LLC to conduct drug and/or alcohol testing of job
applicants for the purpose of detecting drug and/or alcohol abuse. I understand that one of the
requirements for consideration of employment with TruCore Energy LLC is the satisfactory passing of the
companys drug and/or alcohol test(s).
I acknowledge that I have been provided a conditional offer of employment and that I hereby agree to
submit to a drug and/or alcohol test. I understand that unfavorable test results will result in the revocation
of my employment offer by TruCore Energy LLC I also give consent to the testing agency to release to
TruCore Energy LLC and other officially interested parties, the results of my test(s) and other test related
information.
At this time, I consent to the drug and/or alcohol test. I am also providing you with the following list of
prescribed medications that I am currently taking, in anticipation of this test.
Current Prescription Medication:
1.__________________________________

2.___________________________________

3.__________________________________

4.___________________________________

APPLICANT:

Signature:
Printed Name:
Date:

MVR RELEASE INFORMATION

I, __________________________________ (name of prospective driver) hereby authorize the Division

of Motor Vehicles to release my driving record to:
TruCore Energy LLC and any of their authorized agents.
This authorization shall remain on file and in full force and effect during my employment period or until I
file a formal withdrawal.

REQUIRED INFORMATION:
Driver Full Name:
(Print name exactly as it appears on your drivers license)

Drivers License Number: ____________________________ State:

Date of Birth:

Gender:

Signature: ________________________________

SSN#:

Date:

CERTIFICATION OF COMPLIANCE WITH

DRIVERS LICENSE REQUIREMENTS
The requirements in Part 383 apply to every driver who operates in interstate, interstate, or foreign commerce and
operates a vehicle weighing 26,001 pounds or more, can transport 15 people, or transports hazardous materials that
require placarding.
The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle
weighing 10.001 pounds or more, can transport more than 15 people, or transports hazardous materials that require
placarding.
DRIVER REQUIREMENTS: Part 383 and 391 of the Federal Motor Carrier Safety Regulations contain some
requirements that you, as a driver, must comply with, including the following:
POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one
motor vehicle operators license. If you have more than one license, keep the license from your state of
residence and return the additional license to the state(s) that issued them. DESTROYING a license does
not close the record in the state that issued it you must notify the state. If a multiple license has been lost,
stolen, or destroyed, close your record by notifying the state of issuance.
NOTIFICATION OF LICENSE SUSUPENSION, REVOCATION OR CANCELLATION: Sections
392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer
the NEXT BUSINESS DAY of any revocation or suspension of your drivers license. In addition, Section
383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it
within 30 days to: 1) your employing carrier; and 2) the state that issued your license (if the violation
occurs in a state other than the one which issued your license). The notification of both the employer and
state must be in writing.
CDL DOMICILE REQUIREMENT: Section 383.23(a)(2) requires that your commercial drivers license
be issued in your legal state of domicile, where you have your true, fixed and permanent home and
principal residence and to which you have intention of returning whenever you are absent. If you establish
a new domicile in another state, you must apply to transfer your CDL within 30 days.

The following license is the only one I possess:

Drivers License #: ____________________ State:________________Exp. Date:
Drivers Certification:
I certify that I have read and understand the above requirements.
Driver Signature:
___________________________________________________________________________________
Printed Name: _________________________________________Date:________
Certification of Compliance with Drivers License Requirements (rev. 12/12/14)

DRIVER STATEMENT OF ON-DUTY HOURS

(For Newly Hired Drivers)
INSTRUCTIONS: Motor carriers when using a driver for the first time shall obtain from the driver a
signed statement giving the total time on-duty during the immediate preceding 7 days and time at which
such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal
Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days,
including work for non-motor carrier entity, must be recorded on this form.
Driver Information:
Motor Vehicle Operators License Number:
_______________________________________________________________
Type of License: _____________________________ Issuing State: ______________________________
DAY
DATE

7
TOTAL HOURS

HOURS
WORKE
D
I hereby certify that the information given above is correct to the best of my knowledge and belief, and
that I was last relieved at work at: ____________________________ AM
on______________________________________.
Time
Day
Month Year

PM

Date: _________________________________________
Driver Signature_________________________________
1. At this time, do you intend to work for another employer while employed by this company?

Date: ______________________
Driver Signature__________________

Yes No

EMPLOYMENT VERIFICATION
SAFETY PERFORMANCE HISTORY RECORD REQUEST

SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Name: ___________________ Social Security Number: ____________________ Date of Birth: _______________
Previous Employer: ________________________________________________Fax:_____________________
Address: _______________________________________________________ Phone: ______________________
Street

City

State

Zip

In accordance with 40.25(g) and 391.23(h), release of this information must be made in written form that ensures
confidentiality, such as fax, email or letter.
Confidential Fax Number: ___________________________________ Email Address: _______________________
I, __________________________________________ (Applicants name), hereby authorize the above-named
employer to release and forward information requested by Sections 2 and 3 of this document concerning any
employment history, alcohol and controlled substance testing records and other required information within the
previous 3 years from ____________________________________.
Date: _________
Applicants Signature________________________________

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

The Applicant named above was employed by us: Yes No
Employed as ________________________ from (mm/yy) ___________ to (mm/yy) _______________________
1. Did he/she drive a motor vehicle for you? Yes No
Semi-Trailer

If yes, what type? Straight Truck

Tractor

Bus

Cargo Tank
Doubles/Triples
___________________________________
2. Reason for leaving your company?____________________________________________
3.

3. If there is no safety performance to report, check here , sign below and return.
Accidents: Complete the following for any accidents included in your accident register 390.15(b) that involved the
applicant in the last 3 years prior to the application date shown above, or check the following if there is no register
data for the driver.

Date
Location
# of Injuries
# of Fatalities
HazMat Spill
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________
Please provide information concerning any other accidents involving the applicant that were reported to the
government agencies or insurers or retained under internal company policy:
_____________________________________________________________

Employee Name: ______________________________________

Date: _______________________

SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER

DRUG AND ALCOHOL HISTORY: If the driver was NOT subject to the Department of Transportation testing
requirements while employed by this employer, please check here , complete bottom of Section 3 and return.
1. The employee was subject to the Department of Transportation testing requirements from (mm/yy)
_____________________ to (mm/yy) _______________________.
2. Has the employee had an alcohol test result of 0.02 or higher alcohol concentration?
3. Has this person tested positive for controlled substances or refused to test?

Yes No
Yes No
Yes No

4. Has this person committed any other violations 382(b) or Part 40?
5. If this person violated a DOT drug and alcohol regulation, did this person complete a SAP prescribed rehabilitation
program during your employ, including all return-to-duty requirements? Yes No
If yes, forward documentation.
6. For a driver who successfully completed a SAPs program, have they ever had a subsequent alcohol test result of

Yes No

0.02 or greater, a verified drug test or refuse to test?

Name of Person Completing Form:

___________________________________________________________________________
Address:
_________________________________________________________________________________________
Street
City
State
Zip
Section 2 and Section 3 Completed by (Signature):
_______________________________________________________________

SECTION 4: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one): Faxed
_______________________________

Mailed

By (signature): ________________________________________________

Emailed

Date: ___________________________________

SECTION 4B: TO BE COMPLETED BY PROSEPCTIVE EMPLOYER

Complete below when form is received from previous employer

Information was received from: ___________________________________

This was by (check one):

Faxed
_______________________________

Mailed

Date: ___________________________________

Emailed

RELEASE OF CDL HOLDERS

REPORTED
POSITIVE ALCOHOL OR CONTROLLED
SUBSTANCE TEST RESULTS
Use this form to obtain the CDL holders reported positive alcohol or controlled substance
test results information.
This form should ONLY be used if you wish to inquire whether or not a prospective driver (CDL Holder)
has had a positive alcohol or controlled substance test result reported to the Texas Department of Public
Safety in compliance with state law.

THIS FORM IS NOT REQUIRED FOR REPORTING A POSITIVE ALCOHOL OR

CONTROLLED SUBSTANCE TEST.
1. This form must be completed in full and include
Texas Department of Public Safety the
drivers original signature. Motor Carrier Bureau, MSC# 0521
6200 Guadalupe, Building P
2. Deliver, mail or FAX the completed form to: Austin, Texas 78752-4019
Facsimile: 512-424-5310

I,

,
Print Name of CDL Holder

of
,
Print Address of CDL Holder

authorize release of the CDL holders reported positive alcohol or controlled substance test results reported under state law

TruCore Energy LLC

to

Print Name

of

1820 CR 423, Henderson, Texas 75652

Print Address
Driver License Number:

State:

Date of Birth:

If you would like information about how to receive responses by e-mail in the future, please check this box:
Date:
Signature of Driver:

X
Employment Verification (Rev. 12/12/14)