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Thank you for your interest in Chieftain Contract Services, LLC. If you have started or filled out an application with us before within the past year click here to see if we still have it on file.
Chieftain Contract Services, LLC does not, nor will not sell your information to a third party. We keep your information on hand only for our internal use after you submit an electronic application. Be aware that we keep all of our information protected, and under stringent security measures. All information that you are submitting to Chieftain Contract Services, LLC is submitted using encryption. This encryption will make sure that your information, i.e. - Social Security Number does not fall to an unintended person. You agree that if you submit an application to Chieftain Contract Services, LLC that you give us the permission to run a background check, or reference check. Your application will stay on file for one year from submittal.
* Required Information
Type of Applicant Company Driver
Owner / Operator
Driver of Owner / Operator
Recruiter -- Choose Recruiter --
Legal First Name
Legal Last Name
Social Security #
Date of Birth (MM/DD/YYYY)
Required: Please enter your current address, along with any address(es) prior in the last 3 years.
In case of an emergency, please notify
Emergency contact relationship
Is your emergency contact's address different than above?
What is the highest grade you've completed 12
What is the name of the College / Technical Institute you attended?
College / Technical Institute zip
How Many Years of College / Technical have you completed? NA
If you have graduated. what type of degree or certification, do you have? None
Are you eligible to work in the U.S.? Yes No
Are you currently employed? Yes No
Do you have reliable transportation? Yes No
As part of employment at Chieftain Contract Services, LLC you must provide permission for us to make inquiries to past employers. Will you agree to allow Chieftain Contract Services, LLC to send inquiries to past employers? Yes No
Chieftain Contract Services, LLC is a drug and alcohol free working facility. We require a pre-employment drug screen. Will you agree to take a pre-employment drug screen? Yes No
Who referred you to us
Rate of pay expected
In connection with my application for employment (including contract services) with Chieftain Contract Services, LLC, I understand that an investigative consumer report is being requested from DAC Services, Tulsa, Oklahoma. This will include information as to my character, work habits, performance and experience, along with reasons for terminations of past employment from previous employers. Further, I understand that the company will be requesting information concerning my driving record and/or information from various federal, state and other agencies which maintain records concerning traffic offenses, accidents, etc. As well as information from DAC concerning (1) previous driving record request made by others such as state agencies; (2) state provided driving records; (3) claims involving me in the files of insurance companies.
I AUTHORIZE, WITHOUT RESERVATION; ANY PARTY OR AGENCY CONTACTED BY DAC TO FURNISH THE ABOVE-MENTIONED INFORMATION.
I have a right to make a written request within reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I hereby consent to Chieftain Contract Services, LLC obtaining the above information from DAC, and agree that such information which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies, which subscribe to DAC's services.
If hired, I agree I will serve at the will of the Company, and I agree that I shall be bound by the rules, policies, regulations and terms and conditions of employment of the Company as they are from time to time changed with or without notice to me. I AGREE THAT EITHER PARTY MAY TERMINATE THE EMPLOYMENT RELATIONSHIP, WITH OR WITHOUT CAUSE, AT ANY TIME. I agree that these arrangements may only be altered in writing directed to me personally by the President of the Company. I further agree that my employment is conditional upon satisfactory completion of documentation as required by the Immigration Reform and Control Act of 1986 and the results of my pre-employment physical and pre-employment drug screen as stated in the FMCSR (Federal Motor Carrier Safety Regulations) section 40.382.1 are known.
Do you Authorize Chieftain Contract Services, LLC Drivers Notification and Release: Yes No
1. In connection with your application for employment with Chieftain Contract Services, LLC ("Prospective Employer"), it 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 you 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 ELHC ("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 form the previous three (3) years. I understand and acknowledge that this release for 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 check 'Yes' on 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...... Yes No
Have you ever worked for E.L. Hollingsworth & Co., Chieftain Contract Services, or H.E.L.P.( Hollingsworth Expedited Lane Partners) Before?
Worked From (MM/YYYY)
Worked To (MM/YYYY)
Reason for Leaving
** ALL DRIVER APPLICANTS: TO DRIVE IN INTERSTATE COMMERCE, YOU MUST PROVIDE THE FOLLOWING INFORMATION ON ALL EMPLOYERS DURING THE PRECEDING TEN (10) YEARS. PLEASE LIST COMPLETE MAILING ADDRESS, STREET NUMBER, ZIP CODE. APPLICANTS DRIVING A COMMERCIAL MOTOR VEHICLE (INTRASTATE OR INTERSTATE COMMERCE) MUST ALSO PROVIDE AN ADDITIONAL 7 YEARS INFORMATION ON THOSE EMPLOYERS. FOR WHOM THE APPLICANT OPERATED SUCH A VEHICLE.
You must enter at least the past 10 years of your employement history.
Employed From (MM/YYYY)
Reason for leaving
Were you subject to FMCSRs while employed? Yes No
Was this particular job, designated as a safety sensitive function in any DOT related mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No
Have you had any accidents in the past 5 years?
List all accidents that have happened in the past 5 years, starting with the most recent.
Have you had any traffic violations in the past 5 years?
List all traffic violations you have had in the past 5 years, starting with the most recent one.
Please list current license held first, along with any other drivers license's held within the past 10 years.
List experience on class of equipment
Please answer as many questions as you can below
List states operated in for the last 5 years or N/A if not applicable.
List special courses or training received or N/A if not applicable.
List safe driving awards that you have received or N/A if not applicable.
Show any trucking, transportation or other experience that may help you in your work for this company or N/A if not applicable.
List any special equipment or technical materials you can work with, other then specified in this application or N/A if not applicable.
Other Remarks or Information you wish to provide or N/A if not applicable.
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