Suplemental CFR request | FORM Supplemental CFR Request Supplemental 4 CFR request for additional employers not listed on employment application 1. Company InformationI would like to apply for a position with:* Windstar Lines, 1903 North US Hwy 71 Carroll, IA 51401 Phone: 888-494-6378 Fax: 712-792-9615 Windstar Express Inc, 1903 N US Hwy 71, Carroll, IA 51401, Phone 877-499-7377; Fax: 712-792-9615. 2. Applicant InformationName* First Middle Last 1. Current Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Enter Email Confirm Email This is the email address the final application package will be sent to for electronic signature. Please make sure you enter a valid and accessible email address that you will check when you click SUBMIT. You will need to DIGITALLY SIGN the application package before you can be considered for employment. DO NOT FORGET THIS, your application is not submitted until you have digitally signed the application. You may need to check your JUNK EMAIL box.Day Time Phone*Mobile Phone*3. Previous EmploymentList your current or most recent employer first. Please list all jobs (including self-employment and military service) which you have held, beginning with he most recent, and list and explain any gaps in employment. Four fields will be provided, if additional fields are needed, please explain this in the comments field. Please provide ten years employment history if you have it. Please provide ten years history including school if necessary. For those drivers applying to operate a commercial motor vehicle as defined by part 383 of this subchapter, a list of the names and addresses of the applicant's employers during the 7-year period preceding the 3 years contained in paragraph (b)(10) of this section for which the applicant was an operator of a commercial motor vehicle, together with the dates of employment and the reasons for leaving such employment* I have read and understand this information. First Company Name* Company Name DRIVER Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*1. Years with this engagement:*Please make a selection10 or more987654321Less than 11. Were you subject to the FMCSRs while employed by this previous employer?* Yes No Were you subject to the FMCSRs while employed by this previous employer? 1. Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?* Yes No Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?1. Supervisor Name* Name 1. We need a good contact option for your previous employer. This may be either a FAX number or a valid email address. Which would you like to provide?* FAX Number Email Address Both 1. Company FAX*1. Supervisor or HR Email* Enter Email Confirm Email 1. Company Phone*1. Company Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 1. Job Duties* 1. Reason for leaving* Resigned Terminated Laid Off Adventure 1. Beginning Date of Employment* MM slash DD slash YYYY 1. Ending Date of Employment* MM slash DD slash YYYY If you are still employed, please select today's date. 1. Do you intend to remain employed with this employer?* Yes No 1. Rate of pay (per hour)*1. Does this complete your ten year history?* Yes No 2. Company Name* Company Name DRIVER Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*2. Years with this engagement:*Please make a selection10 or more987654321Less than 12. Were you subject to the FMCSRs while employed by this previous employer?* Yes No Were you subject to the FMCSRs while employed by this previous employer? 2. Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?* Yes No Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?2. Supervisor Name* Name 2. We need a good contact option for your previous employer. This may be either a FAX number or a valid email address. Which would you like to provide?* FAX Number Email Address Both 2. Company FAX*2. Supervisor or HR Email* Enter Email Confirm Email 2. Company Phone*2. Company Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 2. Job Duties* 2. Reason for leaving* Resigned Terminated Laid Off Adventure 2. Beginning Date of Employment* MM slash DD slash YYYY 2. Ending Date of Employment* MM slash DD slash YYYY If you are still employed, please select today's date. 2. Do you intend to remain employed with this employer?* Yes No 2. Rate of pay (per hour)*2. Does this complete your ten year history?* Yes No 3. Company Name* Company Name DRIVER Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*3. Years with this engagement:*Please make a selection10 or more9876543213. Were you subject to the FMCSRs while employed by this previous employer?* Yes No Were you subject to the FMCSRs while employed by this previous employer? 3. Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?* Yes No Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?3. Supervisor Name* Name 3. We need a good contact option for your previous employer. This may be either a FAX number or a valid email address. Which would you like to provide?* FAX Number Email Address Both 3. Company FAX*3. Supervisor or HR Email* Enter Email Confirm Email 3. Company Phone*3. Company Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 3. Job Duties* 3. Reason for leaving* Resigned Terminated Laid Off Adventure 3. Beginning Date of Employment* MM slash DD slash YYYY 3. Ending Date of Employment* MM slash DD slash YYYY If you are still employed, please select today's date. 3. Do you intend to remain employed with this employer?* Yes No 3. Rate of pay (per hour)*3. Does this complete your ten year history?* Yes No 4. Company Name* Company Name DRIVER Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).*4. Years with this engagement:*Please make a selection10 or more987654321Less than 14. Were you subject to the FMCSRs while employed by this previous employer?* Yes No Were you subject to the FMCSRs while employed by this previous employer? 4. Job was designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?* Yes No Was this Job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40? 4. Supervisor Name* Name 4. We need a good contact option for your previous employer. This may be either a FAX number or a valid email address. Which would you like to provide?* FAX Number Email Address Both 4. Company FAX*4. Supervisor or HR Email* Enter Email Confirm Email 4. Company Phone*4. Company Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 4. Job Duties* 4. Reason for leaving* Resigned Terminated Laid Off Adventure 4. Beginning Date of Employment* MM slash DD slash YYYY 4. Ending Date of Employment* MM slash DD slash YYYY If you are still employed, please select today's date. 4. Do you intend to remain employed with this employer?* Yes No 4. Rate of pay (per hour)*4. Does this complete your ten year history?* Yes No Did you drive any commercial vehicles for any company in the last ten years that you were unable to list above? Yes No Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer4. Notice to All ApplicantsI certify that the information provided on this application is truthful and accurate. I further certify that the information provided for previous employment is true and correct for the last ten years. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.* I understand and agree to this I authorize the company to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.* I understand and agree to this Date of application* MM slash DD slash YYYY I will click the "SUBMIT" button and then I will be directed to follow the instructions to review and sign the document that has been prepared for me.* By selecting the "SUBMIT" button, you hereby acknowledge that you have CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO IT'S TERMS. Additionally, you understand that your application will not be submitted until you have digitally signed it. READ ME NOW!!!!!!!! You will automatically be re-directed to a digital signature page. If you skip this step, you will not be considered for employment. Please make sure you DIGITALLY SIGN your application.
