Click here for a printer-friendly blank application | |||||
Enter Your Personal Information Required fields are marked with * sign. Please use tab key to advance from field to field. | |||||
First Name: * | Last Name: * | Middle Initial: * | |||
Home Address: * | City: * | ||||
State/Provience: * | Zip: * | ||||
Home Phone: * | Other Phone: | ||||
Date of Birth: * | SSN: * | - - | |||
Email: * | |||||
In case of emergency - Contact: | |||||
Name: * | Phone Number: * | Relationship: * | |||
Previous addresses for the past three years: | |||||||
Address: | |||||||
City: | State: | From: | To: | ||||
Address: | |||||||
City: | State: | From: | To: | ||||
Address: | |||||||
City: | State: | From: | To: | ||||
Commercial Driver's License Information: | |||||||
License Number:* | Type: | State:* | Expiration Date:* | ||||
Endorsements: (Check) |
1.
Double/Triple Trailers 2. Passenger Vehicles |
3.
Tank Vehicles 4. Hazardous Materials |
|||||
List Any Additional License(s) Held In The Past 3 Years: | |||||||
State: | Expiration Date: | ||||||
State: | Expiration Date: | ||||||
Has Your CDL Ever Been Suspended Or Revoked? Yes No | |||||||
If Yes, Please Explain: | |||||||
As we
are interested in your well being, a physical examination |
work experience/employment history
All applicants to driver in interstate commerce must
provide the following information on all employers during the preceding 3
years. list complete info. applicants to drive a commercial motor vehicle
(includes vehicles having a gvwr of 26,001 LBS. or more.
Vehicles designed to transport hazardous materials 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.
Company Name: | |||||
Address: | City: | State: | |||
Supervisor Name: | Why Did You Leave? | ||||
Job Description: | |||||
From: | To: | Phone Number: | |||
Fax Number: | |||||
Subject To FMCSR's | Yes | No | |||
Subject To Drug/Alcohol Testing Requirements Per 49 CFR Part 40? | Yes | No | |||
Company Name: | |||||
Address: | City: | State: | |||
Supervisor Name: | Why Did You Leave? | ||||
Job Description: | |||||
From: | To: | Phone Number: | |||
Fax Number: | |||||
Subject To FMCSR's | Yes | No | |||
Subject To Drug/Alcohol Testing Requirements Per 49 CFR Part 40? | Yes | No | |||
Company Name: | |||||
Address: | City: | State: | |||
Supervisor Name: | Why Did You Leave? | ||||
Job Description: | |||||
From: | To: | Phone Number: | |||
Fax Number: | |||||
Subject To FMCSR's | Yes | No | |||
Subject To Drug/Alcohol Testing Requirements Per 49 CFR Part 40? | Yes | No | |||
Company Name: | |||||
Address: | City: | State: | |||
Supervisor Name: | Why Did You Leave? | ||||
Job Description: | |||||
From: | To: | Phone Number: | |||
Fax Number: | |||||
Subject To FMCSR's | Yes | No | |||
Subject To Drug/Alcohol Testing Requirements Per 49 CFR Part 40? | Yes | No | |||
Company Name: | |||||
Address: | City: | State: | |||
Supervisor Name: | Why Did You Leave? | ||||
Job Description: | |||||
From: | To: | Phone Number: | |||
Fax Number: | |||||
Subject To FMCSR's | Yes | No | |||
Subject To Drug/Alcohol Testing Requirements Per 49 CFR Part 40? | Yes | No | |||
Company Name: | |||||
Address: | City: | State: | |||
Supervisor Name: | Why Did You Leave? | ||||
Job Description: | |||||
From: | To: | Phone Number: | |||
Fax Number: | |||||
Subject To FMCSR's | Yes | No | |||
Subject To Drug/Alcohol Testing Requirements Per 49 CFR Part 40? | Yes | No | |||
Company Name: | |||||
Address: | City: | State: | |||
Supervisor Name: | Why Did You Leave? | ||||
Job Description: | |||||
From: | To: | Phone Number: | |||
Fax Number: | |||||
Subject To FMCSR's | Yes | No | |||
Subject To Drug/Alcohol Testing Requirements Per 49 CFR Part 40? | Yes | No | |||
Company Name: | |||||
Address: | City: | State: | |||
Supervisor Name: | Why Did You Leave? | ||||
Job Description: | |||||
From: | To: | Phone Number: | |||
Fax Number: | |||||
Subject To FMCSR's | Yes | No | |||
Subject To Drug/Alcohol Testing Requirements Per 49 CFR Part 40? | Yes | No | |||
collisions
please list all motor vehicle collisions in which you were
involved
(both commercial and private vehicle)
during the past three years prior to the application date.
• Check here if you had no collisions in the past three years.
DATE | DESCRIPTION | LOCATION | INJURIES/FATALITIES |
traffic convictions and forfeitures
please list all traffic convictions and/or forfeitures
(both commercial and private vehicle) for the past
three years (other than parking).
• Check here if you had no traffic violations in the past three years.
DATE | LOCATION | CHARGE | PENALTY |
driving experience
EQUIPMENT CLASS |
TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.) |
DATES FROM TO |
MILES DRIVEN |
STRAIGHT TRUCK | |||
TRACTOR & TRAILER | |||
TRACTOR & TRAILER | |||
OTHER |
States Driven: | |
List Commodities Hauled: | |
Have
You Had Any Worker's Compensation Claims During The Last Two Years? Dates: |
|
Please Describe Specifics Of Claim: |
education
Select Highest Grade Completed: |
College: |
Other Training: |
Have You Received Any Safety Awards Or Special Training? |
general
Have You Been A Driver For This Company Before? | Yes | No |
If So, When? | ||
Is There Any Reason You Might Be Unable To Perform The Functions Of The Job For Which You Have Applied? | Yes | No |
If So, Explain If You Wish: | ||
Have You Ever Lost Your License For Any Reason? | Yes | No |
Do You Have The Legal Right To Work In The U.S.? | Yes | No |
Can You Provide Proof Of Age (Required For Commercial Drivers)? | Yes | No |
As a prospective employer, we must ask
any applicant for a driving position with our company whether he/she has tested
positive, or refused to test, on any pre-employment drug or alcohol test
administered by an employer to which the applicant applied for, but did not
obtain, "safety-sensitive transportation work" (driving a commercial motor
vehicle) during the past three years.
you must check either yes or no to one of the following
• Yes,
I have tested positive for drugs/alcohol, or refused to take a pre-employment
drug/alcohol test in the three years preceding the date of this application.
• No,
I have not tested positive for drugs/alcohol, or refused to take a
pre-employment drug/alcohol test in the three years preceding the date of this
application.
DOT regulations prohibit our utilizing
you to perform a "safety-sensitive function" (driving a commercial motor
vehicle) if you had a positive test or a refusal to test, until and unless you
provide documents showing successful completion of the return-to-duty process
in accordance with DOT regulations.
must be read and signed by the applicant
391.21 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 the carrier to make such inquiries and
investigations of my personal, employment, driving, 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 agree to abide by the rules and regulations of the carrier as well
as the Federal Motor Carrier Safety Regulations. I also agree and understand
that if I am selected to drive for the carrier that I will be on a probationary
period during which time I may be discharged without recourse.
• Check here if you agree to the above terms and conditions.