Commercial Driver

Application for Employment

Applicant Name

First name

Middle Name

Last name

Phone

Current Address

*If the address above residence less than 3 years, list below all residences for the past 3 years.

Address

Position Applying for

Desired Job Duration

Temporary

Part Time

Full Time

Who referred you?

Rate of pay expected?

Have you ever worked for us before?

Yes

From

Where?

Rate of Pay

Reason For Leaving

Name any relatives employed by this company (Type N/A if none)

Are you currently employed?

Yes

If not, how long since leaving last employment?

Education

Highest grade completed

College

Last School Attended

Military Experience

Are you currently serving in Military Reserves?

Yes

Are you currently serving in National Guard?

Yes

General

Have you ever been bonded?

Yes

Name of bonding company

Have you ever been convicted of a felony?

Yes

If yes, please explain below. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.

Driver Experience & Qualifications

The Federal Motor Carrier Safety Regulations (49CFR391.21 (b) (2) requires that driver applicants state their date of birth and SS #.

DOB

Social Security Number

Physical History

The Federal Motor Carrier Safety Regulations (49CFR391 Subpart E) requires that all driver applicants pass certain physical tests before

they are hired to drive a motor vehicle.

Date of last Department of Transportation prescribed examination

Can you provide a copy?

Yes

Last Examination Copy

Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, leg, hand or arm?

Yes

Alcohol & Controlled Substance Statement

The Federal Motor Carrier Safety Regulations 49CFR40.25(j) requires all persons with applying for a driving position requiring a commercial

drivers license to answer the following questions:

1) Within the last two years, have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work?

Yes

2) Within the last two years, have you ever tested positive, or refused to test, on any type of drug or alcohol test administered by an employer for which you performed safety-sensitive transportation work?

Yes

3) If you answered yes to either 1 or 2 above, can you provide and/or obtain proof that you have successfully completed the DOT return-to-duty requirements?

Yes

Applicant's Signature

Date

Driver's License Information

Driver's licenses held in the past 3 years MUST be shown

Upload a copy of all licenses you've held within the past 3 years

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

Yes

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

Yes

C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?

Yes

If you answered “Yes” to A, B, or C, attach a statement giving details.

Driving Experience

Straight Truck

Type of Equipment (Van, Tank, Flat, etc.)

Dates (From -To)

Approximate Total Miles

Tractor & Semi-Trailer

Type of Equipment (Van, Tank, Flat, etc.)

Dates (From -To)

Twin

Type of Equipment (Van, Tank, Flat, etc.)

Dates (From -To)

Approximate Total Miles

Other

Type of Equipment (Van, Tank, Flat, etc.)

Dates (From -To)

Approximate Total Miles

List states operated in during the last five years:

List special courses or training that will help you as a driver:

List safe driving awards held and who awards were presented by:

Accident History

Accident Review for the past 3 years. Attach documents below. Include dates, nature of accident (head-on, rear-end, upset, etc.)

Accident History Documents

Motor Vehicle Driving Record (MVR)

Traffic Convictions and Forfeitures for the past 3 years other than parking violations. (Include dates, locations, charges, and penalties) Type NONE if none

Employment Record

The Federal Motor Carrier Safety Regulations (49CFR391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have 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 must be explained.

Start with the last or current position, including any military experience, and work back (Attach separate sheet if necessary.)

You are required to list the complete mailing address: street number, city, state and zip code.

Current Employer

Supervisor's Name

Address

Position Held

Dates Employed

Salary

Reason For Leaving

Additional Employment Records Upload

Applicant Must Read & Sign

I certify that I have read and understand all of this employment application. It is agreed and understood that the employer or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and other persons named herein from all liability for any damages on account of his furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks that are pertinent to the job.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, personal reputation, personal characteristics and mode of living.

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

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

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

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.

Applicant's Signature

Date