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Driver Application for Employment

* Indicates the field is required

Personal Description

* Last Name:
* First Name:
* Middle Initial:

* Social Security No.:

* Date of Birth:
* Phone No.:
* Email Address:

Current Address

* Address:
* City:
* State:
* Zip:

Last 3 Years

Address:
City:
State:
Zip:

Address:
City:
State:
Zip:

Address:
City:
State:
Zip:

* In Case of Emergency Notify:
* At Phone No.:
* Position Applying For:

* Have you ever worked for this company before?:

Yes No

If Yes - From		To
	(Month / Year)		(Month / Year)

* Are you employed?:

Yes No

When will you be available?:

* Are you prevented from lawful employment in this country because of immigration status?

Yes No

* Have you ever been convicted of a felony, misdemeanor, or criminal violation?

Yes No

Driver License Information (This information will be verified)

* Valid driver license number:
* State:
* Expiration:

* License type (i.e. COL Class A):
* CDL endorsements:

* Has your license, permit or privilege to operate a motor vehicle ever been denied, revoked or suspended?

Yes No

If yes, explain reason:

* Have you ever been disqualified under §383 or §391 of the federal motor carrier safety regulations?

Yes No

If yes, explain reason:

Education

* Please select the last grade completed

* Do you have full knowledge of the federal motor carrier safety regulations?

Yes No

Driving Experience

Tractor

Number of years:
States you have driven in:

Straight Truck

Number of years:
States you have driven in:

Bus

Number of years:
States you have driven in:

Other

Please specify:
Number of years:
States you have driven in:

Accident Record Last 3 Years (This information will be verified)

Date:
Nature of accident :
(overturn,jack knife, rear end, etc)
No. of fatalities:
No. of injuries:
Commercial Vehicle:	Yes No
Personal Vehicle:	Yes No

Date:
Nature of accident :
(overturn,jack knife, rear end, etc)
No. of fatalities:
No. of injuries:
Commercial Vehicle:	Yes No
Personal Vehicle:	Yes No

Date:
Nature of accident :
(overturn,jack knife, rear end, etc)
No. of fatalities:
No. of injuries:
Commercial Vehicle:	Yes No
Personal Vehicle:	Yes No

Date:
Nature of accident :
(overturn,jack knife, rear end, etc)
No. of fatalities:
No. of injuries:
Commercial Vehicle:	Yes No
Personal Vehicle:	Yes No

Traffic Convictions & Forfeitures (other than parking) Last 3 Years (this information will be verified)

State:
Date:
Charge:
Penalty:
Commercial Vehicle:	Yes No
Personal Vehicle:	Yes No

State:
Date:
Charge:
Penalty:
Commercial Vehicle:	Yes No
Personal Vehicle:	Yes No

State:
Date:
Charge:
Penalty:
Commercial Vehicle:	Yes No
Personal Vehicle:	Yes No

State:
Date:
Charge:
Penalty:
Commercial Vehicle:	Yes No
Personal Vehicle:	Yes No

Employment History

Non-CDL driver applicants must provide 3 years employment history. CDL driver applicants must provide 10 years. We are required under §391.23 to investigate our safety performance history of all Federal Motor carrier Safety Administration regulated employers that you worked for in the preceding 3 years. We are required to investigate your participation in a U.S. D.O.T. mandated drug and alcohol testing program, whether you violated any prohibitions under §382 subpart B, and whether you failed to undertake or complete rehabilitations under §382.605 or subpart O §40 of all U.S. D.O.T. regulated employers that you worked for in the preceding 3 years. You must give written consent for these investigations in order to be considered for employment as a driver. You have due process rights regarding the information received from these investigations under §391.23 (i).

All information obtained from previous employers will be kept confidential.

Last Employer

Name:
Phone No.:
Address:
City:
State:
Zip:
Supervisors Name:

From:

To:

Position:
Reason for leaving:

Did you perform �safety sensitive functions� while employed?:

Yes No

Did you operate a CDL vehicle?:

Yes No

Were you subject to the Federal Motor Carrier safety regulations while employed?:

Yes No

Were you required to participate in a U.S. DOT mandated drug and alcohol testing program?:

Yes No

2nd Last Employer

Name:
Phone No.:
Address:
City:
State:
Zip:
Supervisors Name:

From:

To:

Position:
Reason for leaving:

Did you perform �safety sensitive functions� while employed?:

Yes No

Did you operate a CDL vehicle?:

Yes No

Were you subject to the Federal Motor Carrier safety regulations while employed?:

Yes No

Were you required to participate in a U.S. DOT mandated drug and alcohol testing program?:

Yes No

3rd Last Employer

Name:
Phone No.:
Address:
City:
State:
Zip:
Supervisors Name:

From:

To:

Position:
Reason for leaving:

Did you perform �safety sensitive functions� while employed?:

Yes No

Did you operate a CDL vehicle?:

Yes No

Were you subject to the Federal Motor Carrier safety regulations while employed?:

Yes No

Were you required to participate in a U.S. DOT mandated drug and alcohol testing program?:

Yes No

Notice to Applicant

Applicant-If employer has not explained or given a job description, make sure one is given to you and that you fully understand what is expected of you prior to answering the following.

Can you perform the functions described in the job description? Please explain how, with or without reasonable accommodation, you will be able to perform those functions.

Applicant must read and sign

I agree and understand that any misrepresentation or omissions or facts given on this form shall be considered an act of falsification.

I agree and understand that the carrier or its agents may investigate any and all information given on this form to determine its validity.

I understand that under U.S. DOT regulation �391.23 (i), I cannot bring action or proceeding for defamation, invasion of privacy or interference with a contact against this carrier or any previous employer based on furnishing or using employment history information.

I agree to furnish such additional information and complete such examinations as may be required to complete my driver qualification and employment files.

If hired, I agree to abide by all the rules and policies of this carrier.

* Date:
* Applicant's Signature: