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Driver Application

Current Address

Previous Addresses

Do you have the legal right to work in the United States?
  • - select a option -
  • Yes
  • No
Date of Birth
Can you provide proof of age?
  • - select a option -
  • Yes
  • No
Have you worked for this company before?
  • - select a option -
  • Yes
  • No
From
To
Where?
Rate of Pay:
Position
Reason for Leaving:
Are you employed now?
  • - select a option -
  • Yes
  • No
If not, how long since leaving last employment?
Who referred you?
Expected Rate of Pay:
Have you ever been convicted of a felony?
  • - select a option -
  • Yes
  • No
Is there any reason you might be unable to perform the function of the job for which you have applied?

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during th preceding 3 years. List complete mailing address, street number, city, state, and zip code.nnApplicants 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. n(NOTE: List employers in reverse order starting with the most recent.)nn

Employer 1

Company
Start Date
End Date
Company Address
Zipcode
City
State
Position
Salary/Wage
Reason for leaving
Contact Person
Phone Number
Were you subject to the FMCSRs while employed?
  • - select a option -
  • Yes
  • No
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?
  • - select a option -
  • Yes
  • No

Employer 2

Company
Start Date
End Date
Company Address
Zipcode
City
State
Position
Salary/Wage
Reason for leaving
Contact Person
Phone Number
Were you subject to the FMCSRs while employed?
  • - select a option -
  • Yes
  • No
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?
  • - select a option -
  • Yes
  • No

Employer 3

Company
Start Date
End Date
Company Address
Zipcode
City
State
Position
Salary/Wage
Reason for leaving
Contact Person
Phone Number
Were you subject to the FMCSRs while employed?
  • - select a option -
  • Yes
  • No
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?
  • - select a option -
  • Yes
  • No

Employer 4

Company
Start Date
End Date
Company Address
Zipcode
City
State
Position
Salary/Wage
Reason for leaving
Contact Person
Phone Number
Were you subject to the FMCSRs while employed?
  • - select a option -
  • Yes
  • No
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?
  • - select a option -
  • Yes
  • No

Employer 5

Company
Start Date
End Date
Company Address
Zipcode
City
State
Position
Salary/Wage
Reason for leaving
Contact Person
Phone Number
Were you subject to the FMCSRs while employed?
  • - select a option -
  • Yes
  • No
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?
  • - select a option -
  • 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.nnThe Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or properly 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 material sin a quantity requiring placarding.

Accident Record

Last Accident

Last Accident Date
Nature of Accident
Fatalities
  • - select a option -
  • Yes
  • No
Injuries
  • - select a option -
  • Yes
  • No
Hazardous Material Spill
  • - select a option -
  • Yes
  • No

Next Previous

Last Accident Date
Nature of Accident
Fatalities
  • - select a option -
  • Yes
  • No
Injuries
  • - select a option -
  • Yes
  • No
Hazardous Material Spill
  • - select a option -
  • Yes
  • No

Next Previous

Last Accident Date
Nature of Accident
Fatalities
  • - select a option -
  • Yes
  • No
Injuries
  • - select a option -
  • Yes
  • No
Hazardous Material Spill
  • - select a option -
  • Yes
  • No

Traffic Convictions

and forfeitures for the past 3 years (other than parking violations). If none, please leave empty.

Conviction 1

Location
Date:
Charge
Traffic Conviction Penalty

Conviction 2

Location
Date:
Charge
Traffic Conviction Penalty

Conviction 3

Location
Date:
Charge
Traffic Conviction Penalty

Driver's Licenses

List all driver licenses or permits held in the past 3 years

License 1

State
License NO.
Type
Expiration Date
DL Issue Date:

License 2

State
License NO.
Type
Expiration Date

License 3

State
License NO.
Type
Expiration Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
  • - select a option -
  • Yes
  • No
Has any license, permit or privilege ever been suspended or revoked?
  • - select a option -
  • Yes
  • No

Driving Experience

Straight Truck:
  • - select a option -
  • Yes
  • No
Type of Equipment
  • - select a option -
  • Van
  • Tank
  • Dump
  • Refer
Start Date
End Date
Approx NO. of Miles
Tractor & Semi-Trailer
  • - select a option -
  • Yes
  • No
Type of Equipment
  • - select a option -
  • Van
  • Tank
  • Dump
  • Refer
Start Date
End Date
Approx NO. of Miles
Tractor - Two Trailers
  • - select a option -
  • Yes
  • No
Type of Equipment
  • - select a option -
  • Van
  • Tank
  • Dump
  • Refer
Start Date
End Date
Approx NO. of Miles
Tractor - Three Trailers
  • - select a option -
  • Yes
  • No
Type of Equipment
  • - select a option -
  • Van
  • Tank
  • Dump
  • Refer
Start Date
End Date
Approx NO. of Miles
Motorcoach - School Bus
  • - select a option -
  • More than 8 Passengers
  • More than 15 passengers
  • None
Type of Equipment
  • - select a option -
  • Van
  • Tank
  • Dump
  • Refer
Start Date
End Date
Approx NO. of Miles
Other
List states operated in for last five years:
Show special courses or training that will help you as a driver:
Which safe driving awards do you hold and from whom?
Show any trucking, transportation or other experience that may help 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)
Highest grade completed in High School:
How many years of college?
Last School attended:

Attention

By clicking submit, 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.
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