Driver Employment Application

Date of Application

APPLICANT INFORMATION

Name *

First

Middle

Last

Phone

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Position Applying For *

Date Available for Work

Do you have the legal right to work in the United States *

Yes
No

LICENSE INFORMATION

State

State (copy)

State (copy) (copy)

State (copy) (copy) (copy)

State (copy) (copy) (copy) (copy)

DRIVING EXPERIENCE

Straight Truck Experience - Type of Equipment

Date From - Date To and Approx # of Miles

Tractor & Semi-Trailer Experience - Type of Equipment

Date From - Date To and Approx # of Miles

Other Diving Experience - Type of Equipment

Date From - Date To and Approx # of Miles

ACCIDENT RECORD FOR PAST 3 YEARS

Date - Most Recent First

Nature of Accident (Head-on, rear-end, upset, etc)

# Fatilities | # Injuries | Chemical Spill (Y/N)

Date

Nature of Accident (Head-on, rear-end, upset, etc)

# Fatilities | # Injuries | Chemical Spill (Y/N)

Date

Nature of Accident (Head-on, rear-end, upset, etc)

# Fatilities | # Injuries | Chemical Spill (Y/N)

TRAFFIC CONVECTIONS AND FORFEITURES FOR THE PAST 3 YEARS

(OTHER THAN TRAFFIC VIOLATIONS)

Date Convicted (month/year)

Violation | State of Violation

Penalty

(Forfeited Bond, Collateral and/or Points)

Date Convicted (month/year)

Violation | State of Violation

Penalty

(Forfeited Bond, Collateral and/or Points)

Date Convicted (month/year)

Violation | State of Violation

Penalty

(Forfeited Bond, Collateral and/or Points)

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

Yes
No

if yes

If yes, explain

Has any license, permit, or privilege ever been suspended or revoked?

Yes
No

if yes (copy)

If yes, explain

EMPLOYMENT HISTORY

The Federal Motor Carrier Safety Regulations (49 CFR 319.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you 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 employment in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards (attach separate sheets in necessary). You are required to list the complete mailing address, including street number, city , stat, zip and complete all other information.

Name - Current (most recent) Employer

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From Month/Year - To Month/Year

Reason for Leaving

Salary

Explain any Gaps in Employment (Include month/year and reason)

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

Yes
No

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

Yes
No

Name - Second (most recent) Employer

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From Month/Year - To Month/Year

Reason for Leaving

Salary

Explain any Gaps in Employment (Include month/year and reason)

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

Yes
No

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

Yes
No

Name - Third (most recent) Employer

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From Month/Year - To Month/Year

Reason for Leaving

Salary

Explain any Gaps in Employment (Include month/year and reason)

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

Yes
No

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

Yes
No

Cover Letter, Resume, & References

Click or drag files to this area to upload. You can upload up to 3 files.

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 applicate to provide more information than that required by the Federal Motor Carrier Safety Regulations.

Signature

Name *

First

Last

Today's Date

DRIVER APPLICATION

APPLICANT INFORMATION

LICENSE INFORMATION

DRIVING EXPERIENCE

ACCIDENT RECORD FOR PAST 3 YEARS

TRAFFIC CONVECTIONS AND FORFEITURES FOR THE PAST 3 YEARS

EMPLOYMENT HISTORY