Careers Application Form Step 1 of 11 9% Check one:* Owner Operator Company Driver Owner Operator's Driver Date* Last Name*First Name*Middle Name*Email* Date of Birth* SIN*Home Phone*Cell Phone*Company Name (To be Paid Under)*Emergency Contact Name*Emergency Contact Number*Relationship*Current Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Previous Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Province / State*License #*Class*EndorsementsExpiration Date* Province / State*License #*Class*EndorsementsExpiration Date* Province / State*License #*Class*EndorsementsExpiration Date* 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 convicted of a felony? Yes No Do you have any restrictions to legally enter the U.S.A.? Yes No If the answer to A, B, C, or D is YES, give detailsShow special courses that will help you as a driver:List any Safe Driving Awards heldAccident Record for the past three years (attach sheet if more space is required) Dates Nature of Accident (Head on, rear end, etc.)# of fatalities or injuries, if anyPreventable Dates Nature of Accident (Head on, rear end, etc.)# of fatalities or injuries, if anyPreventableDates Nature of Accident (Head on, rear end, etc.)# of fatalities or injuries, if anyPreventable Traffic Convictions and Forfeitures for the past three years (other than parking violations) LocationLocationDate (dd/mm/yy) ChargePenaltyLocationDate (dd/mm/yy) ChargePenaltyLocationDate (dd/mm/yy) ChargePenalty Employment HistoryHAVE YOU EVER WORKED FOR US IN THE PAST?HAVE YOU EVER WORKED FOR US IN THE PAST? No Yes Dates of employment? Give a Complete Record of all employment for the past ten (10) years, including any unemployment of self-employmentFrom: To: Phone:Present or Last EmployerName:Address:Position Held:Reason for leaving:From: To: Phone:Present or Last EmployerName:Address:Position Held:Reason for leaving:From: To: Phone:Present or Last EmployerName:Address:Position Held:Reason for leaving:From: To: Phone:Present or Last EmployerName:Address:Position Held:Reason for leaving:From: To: Phone:Present or Last EmployerName:Address:Position Held:Reason for leaving: PERSONAL REFERENCESList three persons for reference, other than relatives, who have knowledge of your safety habitsName:Phone:Address:Name:Phone:Address:Name:Phone:Address: To Be Read and Signed by ApplicantIt is agreed and understood that any misrepresentation given above shall be considered an act of dishonesty. It is agreed and understood that Light Speed Logistics Inc. or its agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether the same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. It is agreed and understood that this application for qualification in no way obligates the company to employ the applicant. It is agreed and understood that if qualified, the driver will be on a ninety (90) day probationary period during which time he or she may be disqualified without recourse. 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.SECTION 1: TO BE COMPLETED BY THE PROSPECTIVE EMPLOYEEI, (PRINT)Previous Employer:Current Address:City:SIN:Fax:Phone:Province:Postal Code:CONSENT TO THE RELEASE OF INFORMATION CONCERNING MY ALCOHOL AND CONTROLLED SUBSTANCES TESTING RECORDS / RESULTS TO :Prospective Employer:Light Speed Logistics Inc. 7288 – 84th Street SE Calgary, Alberta T2C 4T6Attention: Tel: Fax:Safety Department 800-397-6009 877-236-9633This is in compliance with US DOT REGULATIONS PART 382.405 (f) and(h), which state: (f) Record shall be made available to a subsequent employer upon receipt of a written request from a driver Disclosure by that subsequent employer is permitted only as expressly authorized by the terms of the driver’s request. (h) An employer shall release information regarding driver’s records as directed by the specific written consent of the driver authorizing release of the information to an identified person. Release of such information by the terms of the employee’s consent 382 413 (a)(b)(c)(e)(f) further state: (a) An employer may obtain, pursuant to a driver’s written consent, any of the information concerning the driver which is maintained under this part by the driver’s previous employers. (b) An employer shall obtain, pursuant to a driver’s consent, information on the drivers alcohol tests with a concentration result of 0.04 or greater, positive controlled substances test results, and refusals to be tested, within the preceding two yeas, which are maintained by the driver’s previous employer under section, no later than 14 calendar days after the first time a driver performs safety-sensitive for an employer.SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER1. Has this person tested positive for a controlled substance test in the last 2 years? Yes No 2. Has this person had a Breath Alcohol Concentration of 0.04 or greater in the last 2 years? Yes No 3. Has this person refused a test in the last 2 years? Yes No Previous Employers Representative Providing Information Date: Driver Name:Driver License # :State:To Whom It May Concern: I hereby authorize my employer, Light Speed Logistics Inc., to obtain at any time, my commercial driver’s abstract. I also authorize Light Speed Logistics Inc. to obtain any required information from my insurance company. Government of Alberta Driver Abstract ConsentA "Driver Abstract" is the product name under which the Alberta Government releases specific information from a person's driving record, which contains: Name Address Date of Birth Height Weight Sex Class Issue Date MVID Number License Number Current Demerit Points Suspended Status Expiration Date Reinstatement conditions (if any) List of violations (Descriptions, Demerit / Merit Points and Suspension Term) A Commercial Driver Abstract (CDA) includes Commercial Vehicle Safety Alliance Inspection (CVSA) Information and all of the above information with the exception of date of birth, height, weight, and sex.PART 1I,ofdeclare that my Driver's License Number is:, my Date of Birth is:, and I give consent for my 3 Year, 5 Year, 10 Year Driver Abstract (SDA), 3 Year, 5 Year, 10 Year Commercial Driver Abstract (SDA), to be released, for the period specified under the subsection 5(1)(a), 5(1)(b)(iii) or 5(1)(b)(v) of AMVIR listed below. AUTHORIZATION TO OBTAIN PSP INFORMATION 1. In connection with your application for employment with Light Speed Logistics Inc. (“Prospective Employer”), we may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). 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. 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 Prospective Employer 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.Date: Signature:Name (Please Print): CONFIDENTIALRECORD OF REFERENCE CHECK FROM PAST EMPLOYERAuthorization to Release Information: I hereby authorize my previous employer(s) to release my past employment and reference information as requested in this document.Signature:Driver's Name (Please Print):Date: Attention:Company:From:Human Resources:Date: Driver Name:Fax: 1st Attempt 2nd Attempt 3rd Attempt 4th Attempt DRIVER DISCLOSURE OF LICENSEPursuant to Section 318.1 (1) of the Highway Traffic ActI, Last Name:First Name:Middle Name:hereby disclose the only jurisdiction in which I am licensed, the class of license held, whether or not the license is suspended, and the name in which the license is issued.Jurisdiction(City/Province):Class:Driver's License Number:Suspended? :I understand that I can possess only one driver’s license. I understand that I must inform my employer immediately of any convictions or accidents while operating a motor vehicle. I understand that I must immediately inform my employer of any suspensions, restrictions, prohibitions,or any change in status to my driver’s license.Date: DECLARATION OF HOURS OF SERVICE Pursuant to Section 318.1 (1) of the Highway Traffic ActI, Last Name:First Name:Middle: Day 1DRIVING HOURSON DUTY (NOT DRIVING) HOURS Day 2DRIVING HOURSON DUTY (NOT DRIVING) HOURS Day 3DRIVING HOURSON DUTY (NOT DRIVING) HOURS Day 4DRIVING HOURSON DUTY (NOT DRIVING) HOURS Day 5DRIVING HOURSON DUTY (NOT DRIVING) HOURS Day 6DRIVING HOURSON DUTY (NOT DRIVING) HOURS Day 7DRIVING HOURSON DUTY (NOT DRIVING) HOURS I understand that I may be asked to provide copies of my log book to verify the above information. Date: This iframe contains the logic required to handle Ajax powered Gravity Forms.