Drivers Application

Date:*
Name:*

Current and THREE years Previous Addresses

Address:*
How long have you lived here? *
Add Another Address:
Address:(1)*
How long have you lived here? (1) *
Add Another address:
Address:(2)*
How long have you lived here? (2) *
Age:*
Phone:*
-
Date of Birth: *

Driver's License

State Issued:*
License Number: *
Medical Card Expiration Date *
Have you worked for this company before? *
From:*
To:*
Reason for leaving:*

Education History

Grade School

Select the highest grade completed: *

College

Select the highest year(s) completed:

Post-Graduate

Select the highest year completed:

Employment History

Give a Complete Record of all employment for the past THREE YEAR, including any unemployment or self employment, and all commercial driving experience for the past TEN YEARS.  

Name of Present or Last Employer:*
Held from: *
To: *
Position Held: *
Address: *
Phone #:*
-
Reason For Leaving:*
Were you subject to the FMCSRs* while employed here? *
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? *
Add another employment record?
Name of Present or Last Employer:(1)*
Held from: (1)*
To: (1)*
Position Held: (1)*
Address: (1)*
Phone #:(1)*
-
Reason For Leaving:(1)*
Were you subject to the FMCSRs* while employed here? (1)*
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? (1)*
Add another employment record? (1)
Name of Present or Last Employer:(1)(1)*
Held from: (1)(1)*
To: (1)(1)*
Position Held: (1)(1)*
Address: (1)(1)*
Phone #:(1)(1)*
-
Reason For Leaving:(1)(1)*
Were you subject to the FMCSRs* while employed here? (1)(1)*
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? (1)(1)*

Driving Experience

In the following section, if you have experience in that class of equipment, include the dates and the approximate number of miles traveled in this equipment area.

Straight Truck:
Tractor and Semi-trailer:
Tractor-two trailers:
Tractor-three trailers (triples):
Other:

For the following section, please check all states that you have operated in, over the last FIVE years.

Check all that apply:
List any Safe Driving Awards you hold and from whom:
List special courses/training competed (PTD/DDC, Haz Mat, etc.)

Accident Record for past THREE years

Accident Record:
Add another accident record:
Accident Record:(1)
Add another accident record: (1)
Accident Record:(1)(1)

Traffic Convictions and Forfeitures for the last THREE years (other than parking violations)

Traffic Convictions:
Add another Traffic Conviction:
Traffic Convictions: (1)
Add another Traffic Conviction: (1)
Traffic Convictions: (1)(1)
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? *
Please Explain: *
B. Has any license, permit or privilege ever been suspended or revoked? *
Please Explain: (1)*
C. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)? *
Please Explain: (2)*
D. Have you ever been convicted of a felony? *
Please Explain: (2)(1)*

It is agreed and understood that any misrepresentation given on this document shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate my background to ascertain any and all information of concern to commercial driving record, whether same is of record or not,

And I release the employers and persons named herein from all liability for any damages on account of their furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.


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


Signature: *
Date Submitted:*