Driver Application

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

* Required fields

** 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.

***The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than eight passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

* required

Position(s) Applied for

Name (Last, First, Middle Initial) *

Email Address *

Social Security No. *

Current Street *

Current City *

Current State *

Current Zip Code

Phone *

How Long? (yr / mo)

List your last addresses of residency for the past three years.

LAST ADDRESS

Address 2 - Street

Address 2 - City, State, Zip Code

Address 2 - How Long?

ADDRESS 3

Address 3 - Street

Address 3 - City, State, Zip Code

Address 3 - How Long?

ADDRESS 4

Address 4 - Street

Address 4 - City, State, Zip Code

Address 4 - How Long?

ADDRESS 5

Address 5 - Street

Address 5 - City, State, Zip Code

Address 5 - How Long?

Have you worked for this company before? *

Where?

Date Started

Date Ended

Rate of Pay

Position

Reason for Leaving

Do you have the legal right to work in the United States? *

Date of Birth *

Can you provide proof of age? *

Are you now employed? *

If not, how long since leaving last employment?

Who referred you?

Have you ever been bonded?

Name of Bonding Company?

Rate of Pay Expected?

If yes, please explain.

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.

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding three years.

Commercial motor vehicle** applicants in intrastate/interstate commerce shall also provide an additional seven years information on those employers they operated such vehicles for.

List complete mailing address, street number, city, state and zip code.

(Note: List employers in reverse order, starting with the most recent.)

MOST RECENT EMPLOYER

Employer 1 Name

Employer 1 Address

Employer 1 City, State, Zip Code

Employer 1 Contact Person

Date From/To (m/y - m/y)

Were you subject to the FMCSRs*** while employed?

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? *

NEXT MOST RECENT EMPLOYER

Employer 2 Name

Employer 2 Address

Employer 2 City, State, Zip Code

Employer 2 Contact Person

Date From/To (m/y - m/y)

Were you subject to the FMCSRs*** while employed?

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?

EMPLOYER 3

Employer 3 Name

Employer 3 Address

Employer 3 City, State, Zip Code

Employer 3 Contact Person

Date From/To (m/y - m/y)

Were you subject to the FMCSRs*** while employed?

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?

EMPLOYER 4

Employer 4 Name

Employer 4 Address

Employer 4 City, State, Zip Code

Employer 4 Contact Person

Date From/To (m/y - m/y)

Were you subject to the FMCSRs*** while employed?

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?

EMPLOYER 5

Employer 5 Name

Employer 5 Address

Employer 5 City, State, Zip Code

Employer 5 Contact Person

Date From/To (m/y - m/y)

Were you subject to the FMCSRs*** while employed?

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?

For last three years or more (if none, write none)

MOST RECENT ACCIDENT

Last Accident Date

Nature of Accident

Fatalities

Injuries

Hazardous Material Spill

NEXT MOST RECENT ACCIDENT

Next Previous Accident Date

Nature of Accident

Fatalities

Injuries

Hazardous Material Spill

ACCIDENT 3

Next Previous Accident Date

Nature of Accident

Fatalities

Injuries

Hazardous Material Spill

TRAFFIC CONVICTIONS AND FORFEITURES

For the last three years or more (if none, write none)

CONVICTION 1

Location 1

Date

Charge

Penalty

CONVICTION 2

Location 2

Date

Charge

Penalty

CONVICTION 3

Location 3

Date

Charge

Penalty

EXPERIENCE AND QUALIFICATIONS - DRIVER

List all driver licenses or permits held in the last three years.

STATE 1

State

License No.

Type

Expiration Date

STATE 2

State

License No.

Type

Expiration Date

STATE 3

State

License No.

Type

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? *

If the answer to either of the last two questions was "Yes," provide details.

Straight Truck

Type

Tank
Flat
Dump
Reefer

Date From/To (m/y - m/y)