Printed Name:

Phone Number:

Date:

Address:

City:

St:

Zip:

Is permanent address different then above?
YesNo

Email:

Social Security Number:

Are you a US citizen or eligible to work in the US?
YesNo

Position you are interested in:

Location(s) you are interested in:

Would you like?
Full timePart time

Preferred work shift?
1st2nd3rd

Do you have a valid Driver's License?
YesNo

Drivers License Number:

State of Issue of Driver's License:

Do you have a valid CDL?
YesNo

When can your start?:

How did you hear about the job?:

Current Employer/Company Name:

City/St:

Job Title:

Duties:

Previous Employer/Company Name:

City/St:

Job Title:

Duties:

I, ___ (CDL Holder Name), hereby provide consent to
KIRK NATIONALEASE, CO. to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (the “Clearinghouse”) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. If KIRK NATIONALEASE, CO. hires me, KIRK NATIONALEASE, CO. may conduct unlimited additional limited queries of the Clearinghouse for the duration of my employment.

I understand that the limited query conducted by KIRK NATIONALEASE, CO. indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to KIRK NATIONALEASE, CO. without first obtaining additional specific consent from me.

I further understand that if I refuse to provide consent for KIRK NATIONALEASE, CO. to conduct a limited query of the Clearinghouse, KIRK NATIONALEASE, CO. must prohibit me from performing safety-sensitive functions, including driving a commercial vehicle, as requested by FMCSA’s drug and alcohol program regulations.

Sign:

Date:

**** Full Application will be requested before hire***