Employee Application Form

Please list your areas of highest proficiency, special skills or other items that may contribute to your abilities in performing the position.

If Yes, for each injury list date of injury, employee at the time, causes of injury, how much time off work, body part involved, & percentage of disability if applicable.

If Yes, for each injury/illness list date, cause, body part involved, how much time off from work and if there is any continuing treatment at this time.

If Yes, list what medications you are currently taking, for what condition you are taking the medication, and any side effects the medications have.

If Yes, please Explain.

If Yes, please Explain (including type of treatment and current restrictions)..

If Yes, please Explain.

I hereby authorize the release of any and all information of my work history to NSGExpress, LLC., for the purpose of investigation as required by Section 391.23 of Federal Motor Carrier Safety Regulations. I understand that information pertaining to test results of Alcohol and Controlled Substances will be required to be obtained under Section 382.413, which states that an employer shall obtain and review the information listed below from any employer the driver performed safety-sensitive function for in the previous three years. safety-sensitive function. The information obtained must include: – Information on the driver’s alcohol test in which a breath alcohol concentration of 0.04 or greater was indicated. – Information on the driver’s controlled substances test in which a positive result was indicated. – Any refusal to submit to a required alcohol or controlled substance test. I Release my previous employers, including their agents and entities, from any liability for release of information requested by NSGExpress, LLC. 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.