Driver Application

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Current Address

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Previous Addresses

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Do you have the legal right to work in the United States?
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  • Yes
  • No
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Date of Birth
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Can you provide proof of age?
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  • Yes
  • No
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Have you worked for this company before?
  • - select a option -
  • Yes
  • No
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From
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To
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Where?
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Rate of Pay:
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Position
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Reason for Leaving:
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Are you employed now?
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  • Yes
  • No
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If not, how long since leaving last employment?
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Who referred you?
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Expected Rate of Pay:
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Have you ever been convicted of a felony?
  • - select a option -
  • Yes
  • No
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Is there any reason you might be unable to perform the function of the job for which you have applied?
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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
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Start Date
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End Date
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Company Address
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Zipcode
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City
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State
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Position
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Salary/Wage
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Reason for leaving
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Contact Person
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Phone Number
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Were you subject to the FMCSRs while employed?
  • - select a option -
  • Yes
  • No
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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
Field is required!

Employer 2

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

Employer 3

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

Employer 4

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

Employer 5

Company
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Start Date
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End Date
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Company Address
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Zipcode
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City
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State
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Position
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Salary/Wage
Field is required!
Reason for leaving
Field is required!
Contact Person
Field is required!
Phone Number
Field is required!
Were you subject to the FMCSRs while employed?
  • - select a option -
  • Yes
  • No
Field is required!
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
Field is required!
*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
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Nature of Accident
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Fatalities
  • - select a option -
  • Yes
  • No
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Injuries
  • - select a option -
  • Yes
  • No
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Hazardous Material Spill
  • - select a option -
  • Yes
  • No
Field is required!

Next Previous

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

Next Previous

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

Traffic Convictions

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

Conviction 1

Location
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Date:
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Charge
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Traffic Conviction Penalty
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Conviction 2

Location
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Date:
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Charge
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Traffic Conviction Penalty
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Conviction 3

Location
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Date:
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Charge
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Traffic Conviction Penalty
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Driver's Licenses

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

License 1

State
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License NO.
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Type
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Expiration Date
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DL Issue Date:
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License 2

State
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License NO.
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Type
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Expiration Date
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License 3

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

Driving Experience

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