Driver application Form

Driver Application

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 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 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 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 current/previous 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.

Signature

Sign Here

Date

Last Name

First Name

Middle

Social Security Number

Phone Number

Date of Birth

Hire Date

PAST 3 YEAR RESIDENCY

Address

City

State

Zip

Number of Years

Address

City

State

Zip

Number of Years

Address

City

State

Zip

Number of Years

EMPLOYMENT HISTORY

(Use additional employment history information section at the bottom of the application if necessary)

All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record).

You are required to list the complete mailing address: street number and name, city, state and zip code.

CURRENT OR LAST EMPLOYER

Name

Phone Number

Street Address

City

State

Zip

Position Held

From

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** while employed?

Yes

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

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

SECOND LAST EMPLOYER

Name

Phone Number

Street Address

City

State

Zip

Position Held

From

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** while employed?

Yes

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

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

THIRD LAST EMPLOYER

Name

Phone Number

Street Address

City

State

Zip

Position Held

From

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** while employed?

Yes

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

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

EXPERIENCE AND QUALIFICATION

DRIVING EXPERIENCE

If no driving experience within the last 3 years, check the box below.

Check Here

Fill out all that apply

Straight Truck

Yes

Type of Equipment

From Date

To Date

OR

Approximate Miles

Tractor & Semi-Trailer

Yes

Type of Equipment

From Date

To Date

OR

Approximate Miles

Tractor - Two Trailers

Yes

Type of Equipment

From Date

To Date

OR

Approximate Miles

Tractor - Three Trailers

Yes

Type of Equipment

From Date

To Date

OR

Approximate Miles

Motorcoach - School Bus (Greater than 8 passengers)

Yes

Type of Equipment

From Date

To Date

OR

Approximate Miles

Motorcoach - School Bus (Greater than 15 passengers)

Yes

Type of Equipment

From Date

To Date

OR

Approximate Miles

ACCIDENT HISTORY (3 YEARS)

If no accidents within the last 3 years, check the box below.

Check Here

ACCIDENT 1

Date

Nature of Accident

Number of Fatalities

Number of Injuries

Hazardous Material Spill?

Yes

ACCIDENT 2

Date

Nature of Accident

Number of Fatalities

Number of Injuries

Hazardous Material Spill?

Yes

ACCIDENT 3

Date

Nature of Accident

Number of Fatalities

Number of Injuries

Hazardous Material Spill?

Yes

TRAFFIC CONVICTIONS AND FORFEITURES (3 YEARS)

If no traffic convictions and/or forfeitures in the last 3 years, check the box below.

Check Here

TRAFFIC CONVICTIONS AND FORFEITURES 1

Date Convicted

Violation

State of Violation

Penalty

TRAFFIC CONVICTIONS AND FORFEITURES 2

Date Convicted

Violation

State of Violation

Penalty

TRAFFIC CONVICTIONS AND FORFEITURES 3

Date Convicted

Violation

State of Violation

Penalty

LICENSE INFORMATION

Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.

State

License Number

Expiration Date

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

Yes

If yes, give details

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

Yes

If yes, give details

APPLICANT CERTIFICATION

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.

Signature

Sign Here

Date

ADDITIONAL EMPLOYMENT (IF REQUIRED)

This section if for additional employment history information. (Note: List employers in reverse order starting with the most recent)

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 commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle. List employers in reverse order starting with the most recent.

ADDITIONAL EMPLOYER 1

Name

Address

City

State

Zip

From Date

To Date

Position Held

Salary/Wage

Reason for Leaving

Contact Person

Phone Number

Were you subject to the FMCRs while employed?

Yes

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

ADDITIONAL EMPLOYER 2

Name

Address

City

State

Zip

From Date

To Date

Position Held

Salary/Wage

Reason for Leaving

Contact Person

Phone Number

Were you subject to the FMCRs while employed?

Yes

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

ADDITIONAL EMPLOYER 3

Name

Address

City

State

Zip

From Date

To Date

Position Held

Salary/Wage

Reason for Leaving

Contact Person

Phone Number

Were you subject to the FMCRs while employed?

Yes

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

ADDITIONAL EMPLOYER 4

Name

Address

City

State

Zip

From Date

To Date

Position Held

Salary/Wage

Reason for Leaving

Contact Person

Phone Number

Were you subject to the FMCRs while employed?

Yes

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

ADDITIONAL EMPLOYER 5

Name

Address

City

State

Zip

From Date

To Date

Position Held

Salary/Wage

Reason for Leaving

Contact Person

Phone Number

Were you subject to the FMCRs while employed?

Yes

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

Driver application Form

TO BE READ AND SIGNED BY APPLICANT

EMPLOYMENT HISTORY

(Use additional employment history information section at the bottom of the application if necessary)

EXPERIENCE AND QUALIFICATION

DRIVING EXPERIENCE

OR

OR

OR

OR

OR

OR

ACCIDENT HISTORY (3 YEARS)

TRAFFIC CONVICTIONS AND FORFEITURES (3 YEARS)

LICENSE INFORMATION

APPLICANT CERTIFICATION

ADDITIONAL EMPLOYMENT (IF REQUIRED)

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