Let's Work Together 〰️ Let's Work Together 〰️ Let's Work Together 〰️ Interested in working together? Fill out some info and we will be in touch shortly! We can't wait to hear from you! Driver Employment Application Applicant Information Name * First Name Last Name Phone * Country (###) ### #### Email * Date of Birth * MM DD YYYY Social Security # * Date of Application * MM DD YYYY Position Applied For * Date Available for Work * MM DD YYYY Do you have legal right to work in the United States? * Yes No Previous Three Years Residency Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Mailing address * Address 1 Address 2 City State/Province Zip/Postal Code Country Previous Address Address 1 Address 2 City State/Province Zip/Postal Code Country Previous Address Address 1 Address 2 City State/Province Zip/Postal Code Country License Information No person who operates a commercial vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed. State * State * Type/Class * A C Endorsements * Expiration Date * MM DD YYYY Previously Held License State License # Type/Class A C Endorsements Expiration Date MM DD YYYY Driving Experience Experience for Straight Truck Type of equipment (van, tank, flat, etc.) Date From MM DD YYYY Date To MM DD YYYY Approx. # of miles (Total) Experience for Tractor & Semi-Trailer Type of equipment (van, tank, flat, etc.) Date From MM DD YYYY Date To MM DD YYYY Approx. # of miles (Total) Experience for Tractor & 2 Trailers Type of equipment (van, tank, flat, etc.) Date From MM DD YYYY Date To MM DD YYYY Approx. # of miles (Total) Experience for Tractor & Tanker Type of equipment (van, tank, flat, etc.) Date From MM DD YYYY Date To MM DD YYYY Approx. # of miles (Total) Experience for Other Type of equipment (van, tank, flat, etc.) Date From MM DD YYYY Date To MM DD YYYY Approx. # of miles (Total) Accident Record for the Past 3 Years Date (List most recent first) MM DD YYYY Nature of Accident (Head-on, Rear-end, Upset, etc.) #Fatalities #Injuries Chemical Spills Yes No Date #2 MM DD YYYY Nature of Accident (Head-on, Rear-end, Upset, etc.) #Fatalities #Injuries Chemical Spills Yes No Date #3 MM DD YYYY Nature of Accident (Head-on, Rear-end, Upset, etc.) #Fatalities #Injuries Chemical Spills Yes No Traffic Convictions and Forfeitures for the past 3 years (other than parking violations) Date MM DD YYYY Violation State of Violation Penalty (Forfeited bond, collateral and/or points) Date MM DD YYYY Violation State of Violation Penalty (Forfeited bond, collateral and/or points) Date MM DD YYYY Violation State of Violation Penalty (Forfeited bond, collateral and/or points) Have you ever been denied a license, permit, or privilege to operate a motor vehicle? * Yes No Has any license, permit, or privilege ever been suspended or revoked? * Yes No 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 (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information. Current (most recent) Employer * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Position Held * Start Date * MM DD YYYY End Date * MM DD YYYY Reason For Leaving * Salary * While employed here, were you subject to the Federal Motor Carrier Safety Regulations? * Yes Nl Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? * Yes Nl second (most recent) Employer Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Position Held Start Date MM DD YYYY End Date MM DD YYYY Reason For Leaving Salary While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes Nl Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? Yes Nl Third (most recent) Employer Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Position Held Start Date MM DD YYYY End Date MM DD YYYY Reason For Leaving Salary While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes Nl Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? Yes Nl Education Highschool/Location * Years Completed * Graduate * Yes No College/Location * Course of Study * Years Completed * Graduate * Yes No Other/Location Course of Study Years Completed Graduate Yes No 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 Name First Name Last Name Date MM DD YYYY Thank you!
