Application | Black Sea Transportation

Application Form

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Date of birth:

SSN / SIN

What position are you applying for?

Company Driver

Owner Operator

Enter Truck Make

Truck year

VIN#

Mileage:

License #

Upload Lisence (FRONT)

Choose File

Upload Lisence (BACK)

Choose File

Confirm Email

Licensing Authority:

License Class:

Country

License Expiration Date:

DOT Medical Card Expiration Date

Endorsements:

Residence address for 3 or more years?

Yes

Add Your Phone Number

Cell:

Are you legally eligible for employment in the United States?

Yes

Do you read, write, and speak English?

Yes

Have you ever worked for this company before?

Yes

Are you currently employed?

Yes

Employer

Current Employer Address:

Address Line 2

City

State

Zip Code

Employed From

Employed To:

Position

Supervisor:

Supervisor's Phone/Mobile

Reason for Leaving:

Previous employers

Previous employers in the past 3 years
(If you had only 1 previous employer please add the same information for Employer #2 and Employer #3 )

Employer # 1

Employer # 1 Name

Date From:

Date To:

Last Employer's Phone #

Last Employer Email:

Position held

Employer # 2

Employer # 2 Name

Date From:

Date To:

Employer # 2 Phone:

Employer # 2 Email:

Position held at Employer # 2

Employer # 3

Employer # 3 Name

Date From:

Date To:

Employer # 3 Phone:

Employer # 3 Email:

Position held at Employer # 3

Employer # 4

Employer # 4 Name

Date From:

Date To:

Employer # 4 Phone:

Employer # 4 Email:

Position held at Employer # 4

Employer # 5

Employer # 5 Name

Date From:

Date To:

Employer # 5 Phone:

Employer # 5 Email:

Position held at Employer # 5

Employer # 6

Employer # 6 Name

Date From:

Date To:

Employer # 6 Phone:

Employer # 6 Email:

Position held at Employer # 6

Employer # 7

Employer # 7 Name

Date From:

Date To:

Employer # 7 Phone:

Employer # 7 Email:

Position held at Employer # 7

Do you have a current TWIC card?

Yes

TWIC Card Number

TWIC Carf Expiration Date:

How many years of Over the road (OTR) do you have?

How did you hear about us?

What's the other place you heard about us from:

Please enter the driver's (Refferal) name:

Emergency Contact 1 - Name

Emergency Contact 1 - Phone#

Emergency Contact 1 - Relationship

Emergency Contact 2 - Name

Emergency Contact 2 - Phone#

Emergency Contact 2 - Relationship

Straight Truck Experience

Less than an year

1-3 years

5+ years

None

Tractor and Semi-Trailer Experience

Less than an year

1-3 years

5+ years

None

Reefer Trailer Experience

Less than an year

1-3 years

5+ years

None

How much experience do you have driving in winter conditions?

Were you involved in any accidents/incidents with any vehicle in the last 5 years (even if not at fault)?

Yes

Explain:

Have you ever been convicted of a crime?

Yes

Explain:

Do you have any deferred prosecutions?

Yes

Explain:

Have you had any moving violations or traffic convictions in the past 3 years?

Yes

Violation Date

Violation State/Province

Charge / Description:

Penalty:

Do you have criminal charges pending?

Yes

Explain:

Have you ever pled "guilty" to, been convicted of, or pled "no contest" to a felony?

Yes

Explain:

Have you, within the last five years, pled "guilty" to, been convicted of, had prosecution deferred in connection with, or pled "no contest" to a misdemeanor?

Yes

Explain:

Are you comfortable driving in winter conditions?

Yes

Do you have at least 2 years tractor and semi trailer experience in the past 4 years?

Yes

Do you have at least 2 consecutive years of OTR experience in the last 3 years?

Yes

Are you in a SAP program?

Yes

Please provide details (SAP program):

FMCSR

Under FMCSR 391.15, are you currently disqualified from driving a commercial motor vehicle? [49 CFR 391.15]

Yes

Has your license, permit or privilege to drive ever been suspended or revoked for any reason? [49 CFR 391.21(b)(9)]

Yes

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?[49 CFR 391.21(b)(9)]

Yes

Within the past two years, have you tested positive, or refused to test, on a pre-employment drug or alcohol test by an employer to whom you applied, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules? [49 CFR 40.25(j)]

Yes

In the past three (3) years, have you ever been convicted of any offenses: [49 CFR 391.15]:

Yes

You can select select multiple options here

I agree to receive information concerning future opportunities or promotions from Black sea transportation LLC by email or other commercial electronic communications

Yes

Checking this box 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

Agree

DISCLOSURES AND AUTHORIZATIONS

First Name

Last Name

DISCLOSURE FOR CONSUMER REPORTS In connection with your employment or owner-operator (independent contractor) application, Black Sea Transportation LLC may order one or more consumer report(s) (commonly known as "background reports" or "background checks") about you from one or more consumer reporting agencies. If you are hired or engaged as an owner-operator (independent contractor), additional consumer reports may be obtained in connection with and throughout your employment for employment purposes or for the legitimate business purpose of evaluating you as an owner-operator. To the extent allowed by law, the consumer reports may include information concerning your character, general reputation, personal characteristics, mode of living, drug and alcohol test results, motor vehicle records, driving records, criminal history, public court records, employment history (including names and dates of previous employers, reason for termination of employment, work experience, and accidents), social security number validation, education, licensure, or verification of other information supplied by you. Such reports may be obtained from private and public record sources, including sanctions databases, CDLIS (including but not limited to CDLIS Central Site, CDLIS Master Pointer Record data and your driver record from the jurisdiction identified in the CDLIS data, in accordance with applicable state law and the Driver Privacy Protection Act), former employers, public court records, and federal, state, and other government agencies that maintain such records.

Agree

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AUTHORIZATION FOR CONSUMER REPORTS I authorize Black Sea Transportation LLC to obtain one or more consumer report(s) or investigative consumer report(s) about me. If hired or engaged as an owner-operator (independent contractor), I understand this authorization shall remain on file and shall serve as ongoing authorization for additional consumer reports or investigative consumer reports to be obtained from any consumer reporting agency at any time during my employment or contract period without asking me for authorization again.

Agree

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IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with Black Sea Transportation LLC ("Prospective Employer"), 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. 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. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication. 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 Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

Agree

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AUTHORIZATION If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize Black Sea Transportation LLC ("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 authorizing 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. 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 challenge 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. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, 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.

Agree

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I hereby provide consent to Black Sea Transportation LLCto conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I understand this consent shall remain on file and shall serve as ongoing consent for Black Sea Transportation LLC to conduct multiple limited queries of the Clearinghouse at any time during my employment or contract period without asking me for additional consent. I understand that if I refuse to provide consent for Black Sea Transportation LLCto conduct a limited query of the Clearinghouse, Black Sea Transportation LLC is required to prohibit me from performing safety-sensitive functions, including operating a commercial motor vehicle. I understand that if the limited query conducted by Black Sea Transportation LLC indicates that drug or alcohol information exists about me in the Clearinghouse, the FMCSA will not disclose that information to Black Sea Transportation LLC unless I give additional specific consent within the Clearinghouse. However, I understand that Black Sea Transportation LLC will be required to conduct a full query of the Clearinghouse within 24 hours after a limited query indicates that drug or alcohol information exists and that if I do not grant consent within the Clearinghouse for that full query I will be removed from performing safety-sensitive functions, including operating a commercial motor vehicle.

Agree

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DISCLOSURE AND AUTHORIZATION UNDER 49 C.F.R. PART 391.23 INCLUDING DOT DRUG AND ALCOHOL INFORMATION For purposes of an investigation in accordance with 49 C.F.R. Part 391.23, I authorize my previous employers, contractors (if owner-operator), and trucking schools, as applicable, to release and forward to Black Sea Transportation LLC ("Company") the following information for the past three (3) years: 1. DOT alcohol and controlled substance information in accordance with Parts 382 and 40 of the Federal Motor Carrier Safety Regulations (49 CFR Part 382 and 49 CFR Part 40, Section 40.25) limited to the following DOT regulated testing items, including pre-employment testing results: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested; (iv) other violations of DOT agency drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) documentation, if any, of completion of the return-to-duty process following a rule violation. 2. Safety performance history information in accordance with 49 CFR Part 391.23, which includes: employment dates, work history (which may include position held, reason for leaving, any termination information, whether subject to the Federal Motor Carrier Safety Administration regulations, equipment experience, area driven, and other information as applicable) and accident information (including accident date, nature of accident, whether it was preventable, whether there were injuries, fatalities, or hazardous materials involved, and copies of any accident report). Pursuant to Section 391.23(i) of the Federal Motor Carrier Safety Regulations, you have the following rights with regard to the information released: 1. You have the right to make a written request at any time to review the information provided by previous employers, contractors (if owner-operator), or trucking schools, as applicable. 2. You have the right to have errors in the information corrected by the previous employer, contractor (if owner-operator), or trucking school, as applicable and for that employer, contractor (if owner-operator), or trucking school to re-send the corrected information. 3. You have the right to have a rebuttal statement attached to the alleged erroneous information if the previous employer, contractor (if owner-operator), or trucking school and you cannot agree on the accuracy of the information.

Agree

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EMPLOYMENT INFORMATION SIGNED CONSENT I AUTHORIZE MY CURRENT OR PAST EMPLOYER TO FURNISH MY EMPLOYMENT INFORMATION. I hereby authorize procurement of my employment information. This authorization shall remain on file and shall serve as ongoing authorization for you to procure my employment information at any time during my employment period.

I authorize

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General Consent for Queries of the Federal Motor Carrier Safety Administration

(FMCSA) Drug and Alcohol Clearinghouse

I hereby authorize Black Sea Transportation LLC to conduct limited annual queries of the FMCSA’s Drug & Alcohol Clearinghouse, to determine if a Clearinghouse record exists for me. This consent is valid from the date shown below until my employment with the above-named municipality ceases or until I am no longer subject to the drug and alcohol testing rules in 49 CFR part 382 for the above-named municipality. I understand that if any full and/or limited query reveals that the Clearinghouse contains information about me, I must grant electronic consent within 24 hours, via the Clearinghouse website, for the employer/motor carrier to obtain my full Clearinghouse record. Refusal to provide such consent will result in my removal from safety-sensitive duties.

I authorize

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I hereby provide consent to the Employer/Motor Carrier (Black Sea Transportation LLC) Safety Department to conduct multiple full and limited queries for the duration of my employment of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I understand that if the multiple full and limited queries conducted by the Employer/Motor Carrier’s Safety Department indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to the Employer/Motor Carrier’s Safety Department without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for the Employer/Motor Carrier’s Safety Department to conduct a multiple full and/or limited query of the Clearinghouse, the Employer/Motor Carrier’s Safety Department must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.

Agree

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By signing my application below, I agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. 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.

Agree

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Consent and Authorization I hereby consent to and expressly authorize Black Sea Transportation LLC to collect, use, and disclose the personal information provided by me in this form for the purpose of contacting and obtaining employment-related information from each of my prior employers listed herein. This authorization extends to the verification of my employment history, qualifications, and any other work-related information deemed necessary by Black Sea Transportation LLC in connection with its review or evaluation process. I understand that this authorization is given voluntarily, that the information obtained may be used solely for employment verification and related purposes, and that it shall remain valid until such time as it is revoked by me in writing, except to the extent that action has already been taken in reliance upon it.

I autorize

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