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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?:
If Yes - From To
(Month / Year)(Month / Year)
* Are you employed?:
When will you be available?:
* Are you prevented from lawful employment in this country because of immigration status?
* Have you ever been convicted of a felony, misdemeanor, or criminal violation?
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?
If yes, explain reason:
* Have you ever been disqualified under §383 or §391 of the federal motor carrier safety regulations?
If yes, explain reason:
Education
* Please select the last grade completed
* Do you have full knowledge of the federal motor carrier safety regulations?
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:
Personal Vehicle:
Date:
Nature of accident :
(overturn,jack knife, rear end, etc)
No. of fatalities:
No. of injuries:
Commercial Vehicle:
Personal Vehicle:
Date:
Nature of accident :
(overturn,jack knife, rear end, etc)
No. of fatalities:
No. of injuries:
Commercial Vehicle:
Personal Vehicle:
Date:
Nature of accident :
(overturn,jack knife, rear end, etc)
No. of fatalities:
No. of injuries:
Commercial Vehicle:
Personal Vehicle:
Traffic Convictions & Forfeitures (other than parking) Last 3 Years (this information will be verified)
State:
Date:
Charge:
Penalty:
Commercial Vehicle:
Personal Vehicle:
State:
Date:
Charge:
Penalty:
Commercial Vehicle:
Personal Vehicle:
State:
Date:
Charge:
Penalty:
Commercial Vehicle:
Personal Vehicle:
State:
Date:
Charge:
Penalty:
Commercial Vehicle:
Personal Vehicle:
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?:
Did you operate a CDL vehicle?:
Were you subject to the Federal Motor Carrier safety regulations while employed?:
Were you required to participate in a U.S. DOT mandated drug and alcohol testing program?:

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?:
Did you operate a CDL vehicle?:
Were you subject to the Federal Motor Carrier safety regulations while employed?:
Were you required to participate in a U.S. DOT mandated drug and alcohol testing program?:

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?:
Did you operate a CDL vehicle?:
Were you subject to the Federal Motor Carrier safety regulations while employed?:
Were you required to participate in a U.S. DOT mandated drug and alcohol testing program?:
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:

 

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