Drivers-Application-For-Employment

DRIVER'S APPLICATION FOR EMPLOYMENT

(Answer All Questions - Please Print)

List your addresses of residency for the past 3 years.

Current Address

Street

City

State

Zip Code

Phone

How Long?

Previous Address

Street

City

State

Zip Code

How Long?

Previous Address

Street

City

State

Zip Code

How Long?

Previous Address

Street

City

State

Zip Code

How Long?

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

Yes No

Date of Birth

(Required for Commercial Drivers)

Can you provide proof of age?

Yes No

Have you worked for this company before?

Yes No

Where

Date From:

Date To:

Rate of Pay

Position

Reason for Leaving

Are you now employed?

Yes No

If not, how long since leaving last employment?

Who referred you?

Rate of Pay Expected

Have you ever been bonded?

Yes No

(Answer only if a job requirement)

Name of Bonding Company

Have you ever been convicted of a felony?

Yes No

If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.

Is there any reason you might be unable to perform the functions of the job for which you have applied?

Yes No

(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 preceding 3 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 years' information on those employers for whom the applicant operated such vehicle.
(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

Previous Employer 1

Name

Address

City

State

Zip

Contact Person

Phone Number

Date From

Date To

Position Held

Salary/Wage

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

Previous Employer 2

Name

Address

City

State

Zip

Contact Person

Phone Number

Date From

Date To

Position Held

Salary/Wage

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

Previous Employer 3

Name

Address

City

State

Zip

Contact Person

Phone Number

Date From

Date To

Position Held

Salary/Wage

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

Previous Employer 4

Name

Address

City

State

Zip

Contact Person

Phone Number

Date From

Date To

Position Held

Salary/Wage

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

Previous Employer 5

Name

Address

City

State

Zip

Contact Person

Phone Number

Date From

Date To

Position Held

Salary/Wage

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

Previous Employer 6

Name

Address

City

State

Zip

Contact Person

Phone Number

Date From

Date To

Position Held

Salary/Wage

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

*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 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Accident Record For Past 3 Years Or More (Attach Sheet If More Space Is Needed).
If None, Write None

Last Accident

Dates

Nature of Accident

(Head-On, Rear-End, Upset, Etc.)

Fatalities

Injuries

Hazardous Material Spill

Next Previous

Dates

Nature of Accident

(Head-On, Rear-End, Upset, Etc.)

Fatalities

Injuries

Hazardous Material Spill

Next Previous

Dates

Nature of Accident

(Head-On, Rear-End, Upset, Etc.)

Fatalities

Injuries

Hazardous Material Spill

Traffic Convictions and Forfeitures For the Past 3 Years (Other Than Parking Violations).
If None, Write None (Attach Sheet If More Space Is Needed)

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

Experience And Qualifications - Driver
List All driver licenses or permits held in the past 3 years.

Driver License

State

License No.

Type

Expiration Date

Driver License

State

License No.

Type

Expiration Date

Driver License

State

License No.

Type

Expiration Date

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

Yes No

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

Yes No

If The Answer To Either A Or B Is Yes, Give Details

Driving Experience

Straight Truck

Yes No

Type Of Equipment

Driven From Date

Driven To Date

Approx Miles

Tractor & Semi-Trailer

Yes No

Type Of Equipment

Driven From Date

Driven To Date

Approx Miles

Tractor - Two Trailers

Yes No

Type Of Equipment

Driven From Date

Driven To Date

Approx Miles

Tractor - Three Trailers

Yes No

Type Of Equipment

Driven From Date

Driven To Date

Approx Miles

Motorcoach - School Bus - More than 8 passengers

Yes No

Type Of Equipment

Driven From Date

Driven To Date

Approx Miles

Motorcoach - School Bus - More than 15 passengers

Yes No

Type Of Equipment

Driven From Date

Driven To Date

Approx Miles

Other Driving Experience

List States Operated In For 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 Your Work For This Company

List Courses And Training Other Than Shown Elsewhere In This Application

List Special Equipment Or Technical Materials You Can Work With (Other Than Those Already Shown)

Education

Highest Grade Completed

High School

1 2 3 4

College

1 2 3 4

Last School Attended

Name

City, State

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

To Be Read And Signed By Applicant

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 authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, 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 regards to inquiries and releasing information in connect with my application.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
I understand that information 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 CFR 391.23(d) and (e). I understand that I have the right to:
- Review information provided by pervious employers
- Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
- Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

Todays Date