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DRIVER EMPLOYMENT APPLICATION

First Name *

Middle Name

Last Name *

Phone *

Email Address *

Date Of Birth *

Social Security # *

Date Of Application *

Position Applied For *

Date Available for Work *

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

Current Address *

City *

State/Province *

ZIP / Postal Code *

Country *

Have you lived at the current address for the last 3 years? *YesNo

Previous Address 1 *

City *

State/Province *

ZIP / Postal Code *

Country *

# Years at the Previous address 1 *

Previous Address 2 *

City *

State/Province *

ZIP / Postal Code *

Country *

# Years at the Previous address 2 *

Previous Address 3 *

City *

State/Province *

ZIP / Postal Code *

Country *

# Years at the Previous address 3 *

LICENSE INFORMATION *No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.

License Number *

License Type/Class *

Endorsements *

Expiration Date *

Previously Held Licenses

Do you have previously held licenses? *YesNo

Previous License Number *

Previous License Type/Class *

Endorsements *

Expiration Date *

Driving Experience

Type of Equipment Operated *

Date From *

Date To *

Approx Miles (Total) *

Accident Record (Past 3 Years)

If None, please indicate below

I have NO Accidents in the past 3 years

Most recent *

Nature of Accident *

# Fatalities *

# Injuries *

Chemical Spill *YesNo

Traffic convictions and Forfeitures for the past 3 years

(Other than parking violations)

I have had NO traffic violations in the past 3 years

Violation *

Date Convicted *

State of Violation *

Penalty *

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

If yes, explain

Has any license, permit, or privilege ever been suspended or revoked? *YesNo

If yes, explain

Employment History

(Please list your employment for the last 3 years.)

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) 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 in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.

Current/Most Recent Employer *

Phone *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Country *

Position Held *

Salary *

USD

Date From *

Date To *

Reason for Leaving *

Explain Any Gaps in Employment *

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *YesNo

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? *YesNo

Second (Most Recent) Employer *

Phone *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Country *

Position Held *

Salary *

USD

Date From *

Date To *

Reason for Leaving *

Explain Any Gaps in Employment *

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *YesNo

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?YesNo

Third (Most Recent) Employer *

Phone *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Country *

Position Held *

Salary *

USD

Date From *

Date To *

Reason for Leaving *

Explain Any Gaps in Employment *

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *YesNo

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? *YesNo

Education

Select

School/College Name *

Location *

Course of Study *

Years Completed *

Graduate *YesNo

OTHER QUALIFICATIONS

Applicant Agreement

I authorize the company to investigate my personal, employment, and other related history as necessary for employment decisions.

I understand that false or misleading information may result in disqualification or termination.

I certify that all information provided is true and complete to the best of my knowledge.

Applicant Signature *

Date *

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