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.

10/24/2017
Applying as:
 
   
()   ()  
*Email:
 
   
 
 

WORK HISTORY

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).

EDUCATION
DRIVING EXPERIENCE

ACCIDENT HISTORY (3 years)
DATE TYPE OF ACCIDENT
TOW/HAZMAT SPILL
FATALITY/INJURY CITATIONS LOCATION AT FAULT?
TRAFFIC CONVICTION and FORFEITURES (last 3 years)


Digital Signature

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










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

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



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

Digital Signature

By checking this box you indicate applicant is authorizing an electronic signature of this document.
1st Request:
2nd Request:
3rd Request:

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


The applicant named below has applied to drive for Farruggio's Express. The applicant listed your company as a past employer from: to . The applicant has signed a release at the bottom of this form.








DRUG & ALCOHOL INFORMATION pursuant to 391and 40.25 (drug & alcohol requesting), include any required DOT drug and / or alcohol testing information within the last three years any obtained from previous employers.
Was applicant in a safety-sensitive DOT-regulated job requiring alcohol & controlled substance testing specified by 49 CFR, P 40?
Has applicant had an alcohol test with a result of 0.04 of higher alcohol concentration?
Has applicant tested positive or adulterated/substituted a test specimen for controlled substances?
Has applicant refused to submit to an alcohol or controlled substance test?
Has applicant had other violations of Subpart B or Part 382or Part 40, Drug and Alcohol Regulations for your company or a previous employer?
If applicant has violated a DOT drug and alcohol regulation, did applicant complete a SAP-prescribed rehabilitation Program while working for your company, including return-to-duty and follow-up tests?
If yes, please provide documentation
Did applicant successfully complete a SAP's rehabilitation program, remained in your employ, and subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested?



APPLICANT, PLEASE COMPLETE AND SIGN BELOW:

 

Digital Signature

By checking this box you indicate applicant is authorizing an electronic signature of this document.
PREVIOUS EMPLOYER: PLEASE COMPLETE AND FAX TO: 215-788-3088 or email to kimf@farruggio.com