To be Read and Signed by Applicant
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) 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.
Applicant's Signature
Date
Applicant Information
Position(s) Applying for:
First Name
Middle Name
Last Name
SSN
Phone
List your addresses for the past 3 years
Current address
Street
Number of Years
City
State
Zip
Past 3 Years
Street
Number of Years
City
State
Zip
Street
Number of Years
City
State
Zip
Date of Birth
Can you provide proof of age?
Have you ever worked for this company before? Yes No
If yes, where?
From:
To:
Position
Rate of Pay
Reason for Leaving
Are you now employed?
If not, how long since leaving last employment?
Who referred you?
Rate of pay expected
Have you ever been bonded? (Answer only if a job requirement)
Name of bonding company?
Have you ever been convicted of a felony?
If yes, please fully explain.
Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.
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)?
If yes, explain if you wish
Employment History
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.
Company
Dates
-
Address
Job Title
Salary/Wage
Contact Person
Phone Number
Reason for Leaving
Were you subject to the FMCSRs** while employed? 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?
Yes No
Company
Dates
-
Address
Job Title
Salary/Wage
Contact Person
Phone Number
Reason for Leaving
Were you subject to the FMCSRs** while employed? 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?
Yes No
Company
Dates
-
Address
Job Title
Salary/Wage
Contact Person
Phone Number
Reason for Leaving
Were you subject to the FMCSRs** while employed? 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?
Yes No
Company
Dates
-
Address
Job Title
Salary/Wage
Contact Person
Phone Number
Reason for Leaving
Were you subject to the FMCSRs** while employed? 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?
Yes No
Company
Dates
-
Address
Job Title
Salary/Wage
Contact Person
Phone Number
Reason for Leaving
Were you subject to the FMCSRs** while employed? 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?
Yes No
Company
Dates
-
Address
Job Title
Salary/Wage
Contact Person
Phone Number
Reason for Leaving
Were you subject to the FMCSRs** while employed? 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?
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.
Driving Record
Accident Record
For the past 3 years or more. Attach a file if more space is needed. If none, write 'None.'
Nature of Accident
Date
Fatalities
Injuries
Hazardous Spills
Nature of Accident
Date
Fatalities
Injuries
Hazardous Spills
Nature of Accident
Date
Fatalities
Injuries
Hazardous Spills
Traffic Convictions and Forfeitures
For the past 3 years (other than parking violations) If none, write 'None.'
Charge
Date
Location
Penalty
Charge
Date
Location
Penalty
Charge
Date
Location
Penalty
Experience and Qualifications - Driver
Driver Licenses
List all driver licenses or permits held in the past 3 years.
State
License Number
Type
Expiration Date
State
License Number
Type
Expiration Date
State
License Number
Type
Expiration Date
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No
B. Has any license, permit or privilege ever been suspended or revoked? Yes No
If the answer to either A or B is yes, give details.
Driving Experience
Check yes or no. If yes, select the type of equipment
Straight Truck Yes No
Type of Equipment Van Tank Flat Dump Refer
From
To
Approximate Miles
Tractor and Semi-Trailer Yes No
Type of Equipment Van Tank Flat Dump Refer
From
To
Approximate Miles
Tractor - Two Trailers Yes No
Type of Equipment Van Tank Flat Dump Refer
From
To
Approximate Miles
Tractor - Three Trailers Yes No
Type of Equipment Van Tank Flat Dump Refer
From
To
Approximate Miles
Motorcoach - School Bus (8+ Passengers) Yes No
Type of Equipment Van Tank Flat Dump Refer
From
To
Approximate Miles
Motorcoach - School Bus (15+ Passengers) Yes No
Type of Equipment Van Tank Flat Dump Refer
From
To
Approximate Miles
List state operated in for the last five years.
List special courses or training that will help you as a driver.
Which safe driving awards do you hold and from whom?
Experience and Qualifications - Other
List 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).
Education
Highest education completed: --- Middle School High School Freshman High School Sophomore High School Junior High School Senior College Freshman College Sophomore College Junior College Senior
Last School Attended
School Address
School City, State
File Upload
Attach any files with additional information as necessary.
Applicant Certification
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.
Applicant's Signature
Date
