Driver Application

Applicant Information

Full Name(Required)

Prefix First Last Suffix

Phone(Required)

Email(Required)

Date of Birth(Required)

Social Security #(Required)

Date of Application(Required)

Position Applied For(Required)

Date Available for Work(Required)

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

Yes

Previous Three Years Residency

Attach additional sheet if more space is needed.

Current Address

Current Address(Required)

Street Address Address Line 2 City State ZIP Code

# of Years at Current Address(Required)

Mailing Address

Street Address Address Line 2 City State ZIP Code

# of Years at Mailing Address

Previous Address 1

Street Address Address Line 2 City State ZIP Code

# of Years at Previous Address 1

Previous Address 2

Street Address Address Line 2 City State ZIP Code

# of Years at Previous Address 2

Previous Address 3

Street Address Address Line 2 City State ZIP Code

# of Years at 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). By completing this section I certify that I do not have more than one motor vehicle license. Include all licenses held for the past 3 years; attach additional sheets if needed.

Current Driver's License

State(Required)

License #(Required)

Type / Class(Required)

Endorsements

Expiration Date(Required)

Previously Held Licenses

State

License #

Type / Class

Endorsements

Expiration Date

Driving Experience

Driving Experience (Class of Equipment, Type, Dates, Approx. Total Miles)

Class of Equipment

Type of Equipment (Van, Tank, Flat, etc.)

Date From

Date To

Approx # of Miles (Total)

Accident Record for the Past 3 Years

Attach additional sheet if more space is needed.

None

No accidents in the past 3 years

Accident Record

Date (most recent first)

Nature of Accident

# Fatalities

# Injuries

Chemical Spills (Y/N)

Traffic Convictions and Forfeitures (Past 3 Years, Excluding Parking Violations)

Attach additional sheet if more space is needed.

None

No convictions/forfeitures in the past 3 years

Traffic Convictions / Forfeitures

Date Convicted (Month/Year)

Violation

State of Violation

Penalty

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

Yes

If yes, explain

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

Yes

If yes, explain

Employment History. 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.

Current (Most Recent) Employer

Employer Name(Required)

Employer Phone

Country Phone Number

Employer Address(Required)

Street Address Address Line 2 City State ZIP Code

Position Held(Required)

From (MO/YR)(Required)

To (MO/YR)(Required)

Reason for Leaving

Salary

Explain Any Gaps in Employment (include month/year & reason)

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

Yes

Was the job designated as a safety-sensitive function subject to alcohol and controlled substances testing (49 CFR Part 40)?

Yes

Second (Most Recent) Employer

Employer Name

Employer Phone

Country Phone Number

Employer Address

Street Address Address Line 2 City State ZIP Code

Position Held

From (MO/YR)

To (MO/YR)

Reason for Leaving

Salary

Explain Any Gaps in Employment (include month/year & reason)

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

Yes

Was the job designated as a safety-sensitive function subject to alcohol and controlled substances testing (49 CFR Part 40)?

Yes

Third (Most Recent) Employer

Employer Name

Employer Phone

Country Phone Number

Employer Address

Street Address Address Line 2 City State ZIP Code

Position Held

From (MO/YR)

To (MO/YR)

Reason for Leaving

Salary

Explain Any Gaps in Employment (include month/year & reason)

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

Yes

Was the job designated as a safety-sensitive function subject to alcohol and controlled substances testing (49 CFR Part 40)?

Yes

Education

Education History

School (High School / College / Other)

Name & Location

Course of Study

Years Completed

Graduate? (Y/N)

Details

Other Qualifications

Please list any other qualifications that you have and which you believe should be considered.

To Be Read and Signed by Applicant. I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to: review information provided by current/previous employers; have errors in the information corrected by previous employers, and for those previous employers to resend 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.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

Applicant Signature (type full name)(Required)

Applicant Name (printed)(Required)

Date(Required)

Driver Application

Driver Employment Application

Applicant Information

Previous Three Years Residency

Current Address

Mailing Address

Previous Address 1

Previous Address 2

Previous Address 3

Current Driver's License

Driving Experience

Accident Record for the Past 3 Years

Traffic Convictions and Forfeitures (Past 3 Years, Excluding Parking Violations)

Current (Most Recent) Employer

Second (Most Recent) Employer

Third (Most Recent) Employer

Education

Other Qualifications

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