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Truck Driver Application

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

Yes

Have you worked for this company before?

Yes

When and where did you work for us? Please provide dates. What was your rate of pay and position? What was your reason for leaving?

Are you now employed?

Yes

When were you last employed?

Who referred you?

Rate of pay expected

Have you ever been bonded?

Yes

Name of bonding company

Have you ever been convicted of a felony?

Yes

Is there any reason you might be unable to perform the functions of the job for which you have applied. If yes, explain if you wish.

Please explain fully. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered

Address

List your addresses of residency for the past 3 years.

Current Address

2nd Address

3rd Address

4th Address

How Long? (yr./mo.)

Employment History

All driver applicants to drive in interstate commerce must provide the following 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 a vehicle. (NOTE: List employers in reverse order starting with the most recent.)

Employer Name

Employer Contact Person (Name & Phone Number)

Position Held

Reason for leaving?

Employer Address

Dates Employed

Salary/Wage

Were you subject to the FMCSRs while employed?

Yes

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alchol testing requirments of CFR part 40?

Yes

Employer Name

Employer Contact Person (Name & Phone Number)

Position Held

Reason for leaving?

Employer Address

Dates Employed

Salary/Wage

Were you subject to the FMCSRs while employed?

Yes

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alchol testing requirments of CFR part 40?

Yes

Employer Name

Employer Contact Person (Name & Phone Number)

Position Held

Reason for leaving?

Employer Address

Dates Employed

Salary/Wage

Were you subject to the FMCSRs while employed?

Yes

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alchol testing requirments of CFR part 40?

Yes

Employer Name

Employer Contact Person (Name & Phone Number)

Position Held

Reason for leaving?

Employer Address

Dates Employed

Salary/Wage

Were you subject to the FMCSRs while employed?

Yes

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alchol testing requirments of CFR part 40?

Yes

Employer Name

Employer Contact Person (Name & Phone Number)

Position Held

Reason for leaving?

Employer Address

Dates Employed

Salary/Wage

Were you subject to the FMCSRs while employed?

Yes

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alchol testing requirments of CFR part 40?

Yes

Accident Record

Please List date of accident, nature of accident (Head-on, Rear-end, Updet, Etc.), Fatalities, Injuries, and Hazardous material spilled.

List any other accidents. List date of accident, nature of accident (Head-on, Rear-end, Updet, Etc.), Fatalities, Injuries, and Hazardous material spilled.

List traffic convictions and forfeitures for the past 3 years (Other than parking violations) If none, write none. Include Location, Date, Charge, and penalty.

Experience and Qualifications

List all driver licenses or permits held in the past 3 years. Please include State, License No., Type, and Expiration Date.

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

Yes

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

Yes

If yes to either of questions to the left, please give details.

Dates in which each class of equipment was used and the number of miles driven with each (Approx).

List states operated in for the last five years

List any special courses or trainings completed that would help you as a driver.

List any safe driving awards and from whom it was awarded.

Please include any qualifications or experience that would quailify you for this position that has not been covered by this application.

What is your highest education level?

Do you have a high school diploma or GED?

Yes

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 for 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 interviews 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 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.

This signature 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.

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