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Driver's Application


In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

Position(s) Applied for

First Name

Middle Name

Last Name

Phone Number (Primary)

Phone Number (Secondary)


List your addresses of residency for the past 3 years.

Current Address

Street

City

State

Zip

How Long? yrs/mths

Previous Address 1

Street

City

State

Zip

How Long? yrs/mths

Previous Address 2

Street

City

State

Zip

How Long? yrs/mths


Do you have the legal right to work in the United States?
 yes no

Date of Birth (required for Commercial Drivers)

Can you provide proof of age?  yes no

Have you worked for this company before?  yes no

If so, what location?

Dates from-to

Rate of Pay

Position

Reason for leaving

Are you currently employed?  yes no

If not; how long since leaving last employment?

Who referred you

Rate of pay expected

Have you ever been bonded?
 yes no

Name of bonding company (Answer only if a job requirement)

Have you ever been convicted of a felony?
 yes no

If yes, please explain fully

(Conviction of a crime is not an automatic bar to employment -all circumstances will be considered)

Is there any reason you might be unable to perform the functions of the job for which you have applied?
 yes no

If yes, explain if you wish.

Employment History
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. Complete name and mailing address, city, state and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle.
(NOTE: List employers in reverse order starting with the most recent.)

Employer Name

Address

City

State

Zip

Contact Person

Date Started - Month/Year

Date Ended - Month/Year

Position Held

Salary/Wage

Reason for Leaving

Were you subject to the FMCSRs† while employed?
 yes no

Was your job designated as a safety sensitive function in any dot-regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?
 yes no

Employer Name

Address

City

State

Zip

Contact Person

Date Started - Month/Year

Date Ended - Month/Year

Position Held

Salary/Wage

Reason for Leaving

Were you subject to the FMCSRs† while employed?
 yes no

Was your job designated as a safety sensitive function in any dot-regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?
 yes no

Employer Name

Street

City

State

Zip

Contact Person

Date Started - Month/Year

Date Ended - Month/Year

Position Held

Salary/Wage

Reason for Leaving

Were you subject to the FMCSRs† while employed?
 yes no

Was your job designated as a safety sensitive function in any dot-regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?
 yes no

Employer Name

Address

City

State

Zip

Contact Person

Date Started - Month/Year

Date Ended - Month/Year

Position Held

Salary/Wage

Reason for Leaving

Were you subject to the FMCSRs† while employed?
 yes no

Was your job designated as a safety sensitive function in any dot-regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?
 yes no

Employer Name

Address

City

State

Zip

Contact Person

Date Started - Month/Year

Date Ended - Month/Year

Position Held

Salary/Wage

Reason for Leaving

Were you subject to the FMCSRs† while employed?
 yes no

Was your job designated as a safety sensitive function in any dot-regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?
 yes no

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

† The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.


Accident Record for Past 3 Years
(add additional in the space below if needed) If none, type none.

Last Accident Date

Nature of Accident (head-on, rearend, upset, etc.)

Fatalities

Injuries

Haz-mat Spill

Last Accident Date 2

Nature of Accident (head-on, rearend, upset, etc.)

Fatalities

Injuries

Haz-mat Spill

Last Accident Date 3

Nature of Accident (head-on, rearend, upset, etc.)

Fatalities

Injuries

Haz-mat Spill

Additional Accident Records for the Past 3 Years


Traffic convictions and forfeitures for the past 3 years (except parking). If none, type 'none'. (add additional in the space below if needed)

Location

Date

Charge

Penalty

Location 2

Dates

Charge

Penalty

Location 3

Date

Charge

Penalty


Experience and Qualifications - Driver

Driver Licenses or Permits Held in the Last 3 Years

State

License Number

Class

Endorsement(s)

Expiration Date

State 2

License Number

Class

Endorsement(s)

Expiration Date

State 3

License Number

Class

Endorsement(s)

Expiration Date

State 4

License Number

Class

Endorsement(s)

Expiration Date


A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
 yes no

B. Has any license, permit or privilege ever been suspended or revoked?
 yes no

If the answer to either A or B is yes, give details


Driver Experience - Check Yes or No

Class of Equipment:

Straight Truck
 yes no

Type of Equipment Operated

Dates (MM/YY)
From - To

Approx. No. of Miles (Total)

Tractor or Trailer
 yes no

Type of Equipment Operated

Dates (MM/YY)
From - To

Approx. No. of Miles (Total)

Tractor - Two Trailer
 yes no

Type of Equipment Operated

Dates (MM/YY)
From - To

Approx. No. of Miles (Total)

Tractor - Three Trailers
 yes no

Type of Equipment Operated

Dates (MM/YY)
From - To

Approx. No. of Miles (Total)

Motorcoach - School Bus 15+ Pass
 yes no

Type of Equipment Operated

Dates (MM/YY)
From - To

Approx. No. of Miles (Total)

Other
 yes no

Type of Equipment Operated

Dates (MM/YY)
From - To

Approx. No. of Miles (Total)


List all states operated in for past five years.

Show special courses or training that will help you as a driver.

Which safe driving awards do you hold and from whom?


Experience and Qualifications - Other

List any trucking, transportation or other experience that may help you in your work for this company.

List courses and training other than shown elsewhere in this application.

List special equipment or technical materials you can work with (other than those already shown)


Education

Check Highest Grade Completed:
 1 2 3 4 5 6 7 8 9

High School:
 1 2 3 4

College:
 1 2 3 4

Name of Last School Attended

City, State


To be read and signed by applicant:

This certifies that this application was completed by me, and that all entries and information on it are true and complete to the best of my knowledge.

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:
- Review information provided by previous employers;
- Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
- Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

Signature (Please type full name)

Date