Driver's Application
for Employment
Applicant name:    Date of applicaton:
Applicant Email:

What is the location of the position that you are applying for?  

In compliance with Federal and State equal employment opportunity laws, qualified application 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.

Applicant to complete
(answer all questions)
Position(s) applied for:

Name:    Social Security No.:
               Last                             First                             Middle
List your addresses of residency for the past 5 years.
Current Address
Street

city
State
Zip code

Phone
 
How Long?
Previous addresses
Street

city
  
State                     Zip code
 
How Long?

Street

city
  
State                     Zip code
 
How Long?

Street

city
  
State                     Zip code
 
How Long?

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

Date of Birth:
(Required for Commercial Drivers)

Have you worked for this company before?      Where?
Dates: From   To    Rate of Pay   Position
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)

Have you ever been convicted of a felony? 

If yes, please explain.
Conviction of a crime is not an automatic bar to employment.


Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the attached 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 preceeding 5 years. List complete mailing address, street number, city , state, and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7.
(NOTE: List employers in reverse order starting withe the most recent.)

CURRENT OR MOST RECENT EMPLOYERDATE
Name FROM
Mo.   Yr.
To
Mo.   Yr.
Address Position held
City    State    Zip Salary/Wage
Contact Person    Phone 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


EMPLOYERDATE
Name FROM
Mo.    Yr.
To
Mo.   Yr.
Address Position held
City    State    Zip Salary/Wage
Contact Person    Phone 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


EMPLOYERDATE
Name FROM
Mo.    Yr.
To
Mo.   Yr.
Address Position held
City    State    Zip Salary/Wage
Contact Person    Phone 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


EMPLOYERDATE
Name FROM
Mo.    Yr.
To
Mo.   Yr.
Address Position held
City    State    Zip Salary/Wage
Contact Person    Phone 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


EMPLOYERDATE
Name FROM
Mo.    Yr.
To
Mo.   Yr.
Address Position held
City    State    Zip Salary/Wage
Contact Person    Phone 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


EMPLOYERDATE
Name FROM
Mo.    Yr.
To
Mo.   Yr.
Address Position held
City    State    Zip Salary/Wage
Contact Person    Phone 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



Accident Record For Past 8 Years Or More.
If None, click on this box

Dates Nature of Accident
(Head-on, Rear-end, Upset, etc.)
Fatalities Injuries Hazardous
Material Spill
Last Accident
Next previous
Next previous
Next previous
Next previous


Traffic Convictions And Forfeitures For The Past 8 Years (other than parking violations)
If None, click on this box

LocationDateChargePenalty


Experience and Qualifications-Driver
List all licenses or permits held in the past 5 years

Drivers
Licenses
State License No. Type Expiration Date


A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? 
B. Has any license, permit,or privelege ever been suspended or revoked? 

If answer to A or B is yes, give details.

Driving Experience check if appropriate
Class of Equipment Type of Equipment Dates
From(M/Y)To(M/Y)
Approx. No. of Miles
(Total)
Straight Truck   Van   Tank   Flat
Dump   Refer
Tractor & semi-trailer   Van   Tank   Flat
Dump   Refer
Tractor & two trailers   Van   Tank   Flat
Dump   Refer
Tractor & three trailers   Van   Tank   Flat
Dump   Refer
Motorcoach-School Bus  
More than 16 passengers
Motorcoach-School Bus  
More than 8 passengers
Other


List States operated in for the last five years

Show 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

Show any trucking, transportation or other experience that may help in you work for this company.


List courses and traning other than shown elsewhere in this application


List special equipment or technical materials you can work with(other than those already shown)


Education
Indicate highest grade completed:
1   2   3   4   5   6   7   8  
High School
9   10   11   12  
College
1   2   3   4  
Last school attended:   City    State




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 necessary in arriving at an employment decision. (Gererally, 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 employment.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understatd, also, that I am required to abide by all rules and regulations of the company.

I understatd that informatin I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 DFR391.23(d) and (e). I understand I have the right to:
  • Review information provided by previous employers:
  • Have errors in the information corrected by previous employers and for those previus employers to re-send the corrected information to the prospective employer: and
  • Have a rebuttal statement attached to the alleged erroneous information, if the previus employer(s) and I cannot agree on the accuracy of the information.

This cerifies that this application was completed by me, and that all entries on it and the information on it are true and complete to the best of my knowlege.

I have read, understand and agree to the above terms and conditions.

Signature:     Date: