DRIVER EMPLOYMENT APPLICATION

PLEASE COMPLETE IN FULL OR YOUR APPLICATION WILL NOT CONSIDERED.

First Name *

Last Name *

Social Security Number *

Date of Birth * +

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Date of application * +

Date available to begin work * +

Position applying for *

PREVIOUS THREE YEARS RESIDENCY

Current Residence

Street address *

City, State and Zip *

# of years at address *

Previous Residence

Street address

City, State and Zip

# of years at address

Previous Residence

Street address

City, State and Zip

# of years at address

Previous Residence

Street address

City, State and Zip

# of years at address

LICENSE INFORMATION

No person who operates a commercial vehicle shall, at any time, have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed beloew.

Please include all licenses held for the past 3 years.

Issuing state *

License Number *

Type/Class *

Endorsements

Issuing state

License Number

Type/Class

Endorsements

Issuing state

License Number

Type/Class

Endorsements

Issuing state

License Number

Type/Class

Endorsements

Issuing state

License Number

Type/Class

Endorsements

DRIVING EXPERIENCE

Class of equipment *

Type of equipment (Van, Tank, Flat, etc.)

Date from +

Date to +

Approx # of miles (Total)

Class of equipment

Type of equipment (Van, Tank, Flat, etc.)

Date from +

Date to +

Approx # of miles (Total)

Class of equipment

Type of equipment (Van, Tank, Flat, etc.)

Date from +

Date to +

Approx # of miles (Total)

Class of equipment

Type of equipment (Van, Tank, Flat, etc.)

Date from +

Date to +

Approx # of miles (Total)

ACCIDENT RECORD FOR THE PAST 3 YEARS

Check "No" if none *

Yes

No

Dates (List most recent first) +

Nature of accident (Head-on, rear-end, upset, etc.) *

# of fatalities (0 if none) *

# of injuries (0 if none) *

Chemical Spills *

Yes

No

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS

(Other than parking violations)

Check "No" if none *

Yes

No

Date Convicted * +

Violation *

State of violation *

Penalty (Forfeited bond, collateral and/or points) *

*Any additional accidents? Check "No" if none *

Yes

No

Date Convicted * +

Violation *

State of violation *

Penalty (Forfeited bond, collateral and/or points) *

**Any additional accidents? Check "No" if none *

Yes

No

Date Convicted * +

Violation *

State of violation *

Penalty (Forfeited bond, collateral and/or points) *

EMPLOYMENT HISTORY

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years.

In addition, if you have driven a commercial vehicle previously , you must provide employment history for an additional seven (7) years for a total of ten (10) years. Any gaps in employemnt in excess of one (1) month must be explained.

Start with the last or current position, including any military experience, and work backwards. You are required to list the complete mailing address, inclduing street number, city, state and zip, as well as complete all other information.

Company Name *

Phone Number *

Street Address *

City *

State *

Zip Code *

Position Held *

From * +

To * +

Reason for leaving *

Salary *

Explain any gaps in employment (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations *

Yes

No

Was the job designated as a safety-sensitive function in any Department of Transportation regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40 *

Yes

No

*Do you wish to add additional employment *

Yes

No

Company Name *

Phone Number *

Street Address *

City *

State *

Zip Code *

Position Held *

From * +

To * +

Reason for leaving *

Salary *

Explain any gaps in employment (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations *

Yes

No

Was the job designated as a safety-sensitive function in any Department of Transportation regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40 *

Yes

No

**Do you wish to add additional employment *

Yes

No

Company Name *

Phone Number *

Street Address *

Position Held *

City *

State *

Zip Code *

From * +

To * +

Reason for leaving *

Salary *

Explain any gaps in employment (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations *

Yes

No

Was the job designated as a safety-sensitive function in any Department of Transportation regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40 *

Yes

No

EDUCATION

HIGH SCHOOL

Name and Location *

Course of study *

Years completed *

Graduate *

Yes

No

Any additional details

COLLEGE

Name and Location *

Course of study *

Years completed *

Graduate *

Yes

No

Any additional details

OTHER EDUCATION

Name and Location

Course of study

Years completed

Graduate

Yes

No

Any additional details

Please list any other qualifications that you have which you believe should be considered.

Please upload your resume here *

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to:

• Review information provided by current/previous employers;
• Have errors in the information corrected by previous employers, and for those previous employers to resend 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.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

TO BE READ AND SIGNED BY APPLICANT

Applicant Name *

Date * +

Applicant signature *

clear

EMERGENCY CONTACT

Name *

Relationship *

Phone number *