Nancy Baer Trucking   3137 Virginia Ave.   Jasper Indiana   1-800-457-7418
Online Application
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
is required during employment at the discretion of the Company.

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.