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Applications

Driver Application

* is reqiurement.

Your Legal Full Name(First Name, Middle Initial, Last Name):

Position Applying for

Check all possible position

*
Phone Number
Emergency Phone Number
*
Date of Birth

ex) 05/23/82 (The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less then 70 years of age.)

*
SSN#

ex) 123-45-6789

*
Physical Exam Expiration Date

mm/dd/yy

*
Current Addresses:
Previous Three Years Addresses:
Have you worked for this company?
If yes, give dates:

from mm/dd/yy to mm/dd/yy

Reason for Leaving?

Please choose
the highest grade completed:

Select One


Employment History

Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years.


- 1st Employment

Employer Name
Starting(Month/Year)

Starting mm/yy

Ending(Month/Year)

mm/yy

Position Held
Reason for leaving

Were you subject to
the FMCSRs while employed here?

Select One
49 CFR Part 40?

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?

Address
Company Phone

- 2nd Employment

Employer Name
Starting(Month/Year)

mm/yy

Ending(Month/Year)

mm/yy

Position Held
Reason for leaving

Were you subject to
the FMCSRs while employed here?

Select One
49 CFR Part 40?

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?

Address
Company Phone

- 3rd Employment

Employer Name
Starting(Month/Year)

mm/yy

Ending(Month/Year)

mm/yy

Position Held
Reason for leaving

Were you subject to
the FMCSRs while employed here?

Select One
49 CFR Part 40?

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?

Address
Company Phone


Driving Experience


- Straight Truck

From

mm/yy

To

mm/yy

Approximate Number of Miles

- Tractor & Semi-Trailer

From

mm/yy

To

mm/yy

Approximate Number of Miles

- Tractor & Two-Trailer

From

mm/yy

To

mm/yy

Approximate Number of Miles

- Tractor & Triple-Trailer

From

mm/yy

To

mm/yy

Approximate Number of Miles

- Others

From

mm/yy

To

mm/yy

Approximate Number of Miles


List states operated in,
for the last five (5) years:

Type in:

List special courses/training
completed (PTD/DDC, HAZMAT, ETC)

Type in:

List any Safe Driving Awards
you hold and from whom:

Type in:


- Accident Record for past three (3) years: (use Notes on bottom, if more space is needed):


1st Accident

Date of Accident
Nature of Accidents

(Head on, rear end, etc)

Location of Accident
# of Fatalities
# of People Injured

2nd Accident

Date of Accident
Nature of Accidents

(Head on, rear end, etc)

Location of Accident
# of Fatalities
# of People Injured

3rd Accident

Date of Accident
Nature of Accidents

(Head on, rear end, etc)

Location of Accident
# of Fatalities
# of People Injured

4th Accident

Date of Accident
Nature of Accidents

(Head on, rear end, etc)

Location of Accident
# of Fatalities
# of People Injured



- Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):


1st Traffic Convictions and Forfeitures

Date
Location
Charge
Penalty

2nd Traffic Convictions and Forfeitures

Date
Location
Charge
Penalty

3rd Traffic Convictions and Forfeitures

Date
Location
Charge
Penalty

4th Traffic Convictions and Forfeitures

Date
Location
Charge
Penalty

5th Traffic Convictions and Forfeitures

Date
Location
Charge
Penalty


- Driver's License (list each driver's license held in the past three(3) years:


1. Driver License

State
License
Type
Endorsements
Expiration Date

2. Driver License

State
License
Type
Endorsements
Expiration Date

3. Driver License

State
License
Type
Endorsements
Expiration Date

4. Driver License

State
License
Type
Endorsements
Expiration Date

5. Driver License

State
License
Type
Endorsements
Expiration Date




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

Select one

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

Select One

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)?

Select One

Have you ever been convicted of a felony?

Select One

If the answers to any questions listed above are "yes",

give us details



Job References


List three (3) persons for references, other than family members, who have knowledge of your safety habits.


1. Job Reference

Name
Address
Phone Number

2. Job Reference

Name
Address
Phone Number

3. Job Reference

Name
Address
Phone Number

Notes

Click Here uploading pictures of [CDL] and [Medical Card]
0 file(s) attached ( / )



To Be Read and Submit by Applicant:


It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to obtain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information.
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 investigating Consumer Report, including information regarding my character, general 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 application file.

It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

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



*
I hereby declare that all the information mentioned in my resume is true and correct to my knowledge and I take full responsibility for the accuracy of the particulars mentioned.
I hereby declare that the details furnished above are true and correct to the best of my knowledge.

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