Name
Email
Phone Number
Emergency Number
Date of Birth
Social Security Number
Physical Exam Expiration Date
Current Address
City, State, Zip
Previous Address 1
City, State, Zip
Previous Address 2
City, State, Zip
If Yes, Please Provide The Dates
Reson For Leaving
Highest Level of Education Completed? Some high school, no diploma High school graduate, diploma, or GED Some college credit, no degree Trade, technical, or vocational training Associate degree Bachelor's degree Master's degree PhD or higher Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self-employment periods, and all commercial driving experience for the past ten (10) years.
Current or Most Recent Employer Company Name
Start Date
End Date
Employer Address
Employer Phone Number
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 for 49 CFR Part 40?
Previous Employer Information Company Name
Start Date
End Date
Employer Address
Employer Phone Number
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 for 49 CFR Part 40?
Previous Employer Information Company Name
Start Date
End Date
Employer Address
Employer Phone Number
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 for 49 CFR Part 40?
Previous Employer Information Company Name
Start Date
End Date
Employer Address
Employer Phone Number
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 for 49 CFR Part 40? The following section is for information regarding your driving history, experience, accidents and awards
Equipment Classes Do You Have Straight Truck Experience? Years Of Experience?
Number of Miles Driven?
Do You Have Tractor & Semi-Trailer Experience? Years Of Experience?
Number of Miles Driven?
Do You Have Tractor & Two Trailers Experience? Years Of Experience?
Number of Miles Driven?
Do You Have Tractor & Three Trailers Experience? Years Of Experience?
Number of Miles Driven?
Other
Years Of Experience?
Number of Miles Driven?
List states operated in, for the last five (5) years
List special courses/training completed (PTD/DDC, HAZMAT, etc)
List any Safe Driving Awards you hold and from whom
Accident Record Accident Record for the past three (3) years
Accident Date
Accident Type
Accident Location
Number of Injuries
Number of Fatalities
Accident Date
Accident Type
Accident Location
Number of Injuries
Number of Fatalities
Accident Date
Accident Type
Accident Location
Number of Injuries
Number of Fatalities
Accident Date
Accident Type
Accident Location
Number of Injuries
Number of Fatalities
Traffic Convictions Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations)
Violation Date
Violation Location
Charge
Penalty
Violation Date
Violation Location
Charge
Penalty
Violation Date
Violation Location
Charge
Penalty
Violation Date
Violation Location
Penalty
Charge
Licenses Driver’s License (List each driver’s license held in the past three (3) years
State
License
Type
Endorsement
Expiration Date
State
License
Type
Endorsement
Expiration Date
State
License
Type
Endorsement
Expiration Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle? Has any license, permit or privilege ever been suspended or revoked? 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)? List three (3) persons for references, other than family members, who have knowledge of your safety habits.
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information. I agree to furnish such additional information and complete such examinations as may be required to complete my application file. It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on the probationary period during which time I may be disqualified without recourse.
Send
