Farruggio's Express -"Best Calling for Hauling"

Before completing and submitting the application below, please open, print, and complete our release form (click here to download it). This file requires Adobe Reader to open and print it. If you do not already have Adobe Reader installed on your computer, you may download and install it for free at http://www.adobe.com/products/acrobat/readstep2.html.

After you complete and submit the driver application, the completed release form must be faxed or mailed to us at:

Fax: (215) 788-3088 (attn: Kim Farruggio-Pearson)

Mailing address:

Kim Farruggio-Pearson
Farruggio's Express
1419 Radcliffe Street
Bristol, PA 19007

Please note that we cannot process your application until the signed release form has been received.

We will contact you shortly after receiving the completed release form.

Date: 04/23/2024	Location:
Applying as: Owner Operator Company Driver

*Name:
	*Last	*First	Middle		*Social Security Number

*Phone:	()			Cell:	()			*Date of Birth:
*Email:

*Address
	Street	City	State	Zip	# of Yr/Mo
Past 3 Years Residency
Past 3 Years Residency	Street	City	State	Zip

Referred By:

Select all that apply: City OTR Independent Contractor Driver For I/C Driver Only

Trailer Needed: Yes No Type:

Years of Experience: Year of Truck: Date of Last Annual Inspection:

CDL#: State:

Endorsements: Restrictions:

In case of emergency notify: Phone: ()

PAST ALCOHOL AND CONTROLLED SUBSTANCE HISTORY Have you ever tested positive, or refused to test, on any drug or alcohol test? Yes No

Have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past three years? Yes No Substance Abuse Professional Name/Number:

WORK HISTORY

All applicants must provide all employers during the preceding three years, and up to ten years if driving. List complete address and phone number for each employer. Add additional sheet if necessary. All time must be accounted for including military service, school, self-employment and periods of unemployment – NO GAPS!

Any gaps between jobs MUST be explained. Make sure you list each motor carrier, the company that was listed on the side of the truck (not the owner of the truck).

CURRENT OR LAST EMPLOYER

Name: Phone Number: ()

Street Address: City: State: Zip:

Position Held: From: To:

Reason for Leaving:

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

DO NOT CONTACT CURRENT EMPLOYER

SECOND TO LAST EMPLOYER

Name: Phone Number: ()

Street Address: City: State: Zip:

Position Held: From: To:

Reason for Leaving:

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

THIRD TO LAST EMPLOYER

Name: Phone Number: ()

Street Address: City: State: Zip:

Position Held: From: To:

Reason for Leaving:

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

PRIOR EMPLOYER

Name: Phone Number: ()

Street Address: City: State: Zip:

Position Held: From: To:

Reason for Leaving:

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

PRIOR EMPLOYER

Name: Phone Number: ()

Street Address: City: State: Zip:

Position Held: From: To:

Reason for Leaving:

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

PRIOR EMPLOYER

Name: Phone Number: ()

Street Address: City: State: Zip:

Position Held: From: To:

Reason for Leaving:

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

PRIOR EMPLOYER

Name: Phone Number: ()

Street Address: City: State: Zip:

Position Held: From: To:

Reason for Leaving:

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

EDUCATION

DRIVING EXPERIENCE

If no driving experience within the last 3 years, check here

ACCIDENT HISTORY (3 years)

If no accidents within the last 3 years, check here

DATE

TYPE OF ACCIDENT
TOW/HAZMAT SPILL

FATALITY/INJURY

CITATIONS

LOCATION

AT FAULT?

Yes

TRAFFIC CONVICTION and FORFEITURES (last 3 years)

If no traffic convictions and/or forfeitures in the last 3 years, check here

DATE CONVICTED	OFFENSE TYPE (other than parking)	STATE	VEHICLE TYPE

If no violations are listed, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months.

Check Here: Type Name Here:

Digital Signature

By checking this box you indicate applicant is authorizing an electronic signature of this document.

Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license, the information for which is listed below.

License Number: State: Expires:
If you have more than one license, return to the state issuance. If a license has been lost, stolen, or destroyed, you must notify the state that you no longer want to be licensed by that state.

IF YOUR LICENSE IS SUSPENDED YOU MUST NOTIFY YOUR EMPLOYER THE NEXT BUSINESS DAY. Part 383 requires that anytime you violate a state or local traffic law, it must be reported within 30 days to your motor carrier *and* to the state of issuance. These notifications MUST be in writing. Additional licenses previously held:
State	License Number	Endorsements	Restrictions	Expiration Date
I certify that I have read and understood the above requirements:
*Name			*Date
Digital Signature By checking this box you indicate applicant is authorizing an electronic signature of this document.

TRUCKING INDUSTRY:

DOT D/A Disclosure and Authorization

Send to Fax #: (215) 788-3088

Helpe Customer Company Name: Farruggio's Express
Company Contact Name: Jim Henderson

Fax #: (215) 788-3088
Helpe Customer #: 131441

PART I – DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES – 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to Helpe for the purpose Helpe transmitting such records to the Helpe customer listed above. I understand that information/documents released pursuant to this Part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation.

If any company listed below furnishes Helpe with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to Helpe, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years.

List all DOT-regulated employers you have applied with and/or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature.

Previous DOT-Regulated Employer	City	State	Phone Number

By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.
*Applicant Name: *Social Security#:
*Date:

Digital Signature

By checking this box you indicate applicant is authorizing an electronic signature of this document.

DOT Drug/Alcohol Disclosure/Authorization
Trucking Industry – Employment Purpose

CONTRACTOR and/or CONTRACTOR DRIVER APPLICANT CERTIFICATION 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. I hereby understand and acknowledge that unless otherwise defined by applicable law, the specific terms and references contained in the Driver Work History document do not constitute an application for employment with this carrier but, represent a work history record only, for the purpose of driver qualification, as set forth in Part §391 in the FMCSA. This is an independent contractor, not an employee position and without regard to race, color, religion, sex, origin, age, marital status, veteran status, or other protected group status. My signature also authorizes carrier and any of its agents, contractors, employees to make investigations and inquire about my work, motor vehicle records, medical, financial, credit standing, drug/alcohol history, and any other inquires as well as releasing carrier and all organizations including Hire Right from any and all liability arising out of or related to responding to inquires from carrier and releasing any information in connection with my application. I recognize that any false information I provide may result in carrier terminating my contracts as on owner operator and /or business relationship. I am certifying that the carrier may also run a DIR report. My signature also states that I have received, read, and agreed to the Company Policies and Instructions manual and it’s contents. I understand that I have a right to 1) review information provided by the previous employers, 2) have errors corrected by previous employers, 3) have the previous employer forward corrected information to the prospective employer, and 4) have a rebuttal statement attached to the allegedly erroneous information if the previous employer and I cannot agree on the accuracy. To review information from previous employers submit a written request to Farruggio's Express, 1419 Radcliffe St., Bristol, PA 19007 along with a photocopy of your license and social security card within 30 days.
Name: Date:
Digital Signature By checking this box you indicate applicant is authorizing an electronic signature of this document.

TRUCKING INDUSTRY:

DOT D/A Disclosure and Authorization

PART I – DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES – 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

Farruggio's Express 1419 Radcliffe St. Bristol, PA 19007 Phone: 215-788-5596 Fax: 215-788-3088

Farruggio's Express
1419 Radcliffe St. Bristol, PA 19007
Phone: 215-788-5596 Fax: 215-788-3088