Drivers Application for Employment

Step 1 of 28

Applicant Name*
Date of Application*
MM slash DD slash YYYY
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.
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 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.
Signature*
Date of Signature*
MM slash DD slash YYYY
APPLICANT TO COMPLETE

(Answer all questions.)
Job Location*
Position Applied For*
Name (last, first, middle)*

List your addresses of residency for the past three years.
Current Address*
Street Address City State ZIP Code
Current Phone*
How long at this address?*

Previous Address #1
Street Address City State ZIP Code
Previous Address #1 Phone
How long at this address?

Previous Address #2 Address
Street Address City State ZIP Code
Previous Address #2 Phone
How long at this address?

Do you have the legal right to work in the United States?*
- Yes
- No
Date Of Birth (Required for Commercial Drivers)
MM slash DD slash YYYY
Can you provide proof of age?*
- Yes
- No
Have you worked for this company before?*
- Yes
- No
If so, where?*
Dates
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Rate of Pay*
Position*
Reason for Leaving*

Are you now employed?*
- Yes
- No
If not, how long since leaving your last employment?*
Who referred you?
Rate of Pay Expected
Have you ever been bonded?*
- Yes
- No
Name of bonding company*
Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?*
- Yes
- No
If yes, explain if you wish.

EMPLOYMENT HISTORY

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 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.)

Employer #1
Previous Employer #1 Name
Previous Employer #1 Address
Street Address City State ZIP Code
Previous Employer #1 Contact Person
Previous Employer #1 Phone
Employer #1 Start Date
MM slash DD slash YYYY
Employer #1 End Date
MM slash DD slash YYYY
Previous Employer #1 Position Held
Previous Employer #1 Salary/Wage
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?*
- Yes
- No
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
- No
* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

†The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers(including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Employer #2
Previous Employer #2 Name
Previous Employer #2 Address
Street Address City State ZIP Code
Previous Employer #2 Contact Person
Previous Employer #2 Phone
Employer #2 Start Date
MM slash DD slash YYYY
Employer #2 End Date
MM slash DD slash YYYY
Previous Employer #2 Position Held
Previous Employer #2 Salary/Wage
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?*
- Yes
- No
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
- No
* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

†The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers(including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Employer #3
Previous Employer #3 Name
Previous Employer #3 Address
Street Address City State ZIP Code
Previous Employer #3 Contact Person
Previous Employer #3 Phone
Employer #3 Start Date
MM slash DD slash YYYY
Employer #3 End Date
MM slash DD slash YYYY
Previous Employer #3 Position Held
Previous Employer #3 Salary/Wage
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?*
- Yes
- No
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
- No
* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

†The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers(including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Employer #4
Previous Employer #4 Name
Previous Employer #4 Address
Street Address City State ZIP Code
Previous Employer #4 Contact Person
Previous Employer #4 Phone
Employer #4 Start Date
MM slash DD slash YYYY
Employer #4 End Date
MM slash DD slash YYYY
Previous Employer #4 Position Held
Previous Employer #4 Salary/Wage
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?*
- Yes
- No
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
- No
* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

†The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers(including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Employer #5
Previous Employer #5 Name
Previous Employer #5 Address
Street Address City State ZIP Code
Previous Employer #5 Contact Person
Previous Employer #5 Phone
Employer #5 Start Date
MM slash DD slash YYYY
Employer #5 End Date
MM slash DD slash YYYY
Previous Employer #5 Position Held
Previous Employer #5 Salary/Wage
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?*
- Yes
- No
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
- No
* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

†The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers(including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Employer #6
Previous Employer #6 Name
Previous Employer #6 Address
Street Address City State ZIP Code
Previous Employer #6 Contact Person
Previous Employer #6 Phone
Employer #6 Start Date
MM slash DD slash YYYY
Employer #6 End Date
MM slash DD slash YYYY
Previous Employer #6 Position Held
Previous Employer #6 Salary/Wage
Reason for Leaving
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?*
- Yes
- No
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
- No
* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

†The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers(including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE
Have you been in a vehicle accident in the last three years?*
- Yes
- No
If yes, please document below.
Accident Date*
MM slash DD slash YYYY
Nature of Accident (head-on, rear-end, upset, etc.)*
Fatalities*
Injuries*
Hazardous Material Spill*

Accident #2
Accident Date
MM slash DD slash YYYY
Nature of Accident (head-on, rear-end, upset, etc.)
Fatalities
Injuries
Hazardous Material Spill

Accident #3
Accident Date
MM slash DD slash YYYY
Nature of Accident (head-on, rear-end, upset, etc.)
Fatalities
Injuries
Hazardous Material Spill
Have you been involved in more than these three vehicle accidents in the past three years?*
- Yes
- No

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
Have you been involved in any traffic convictions or forfeitures in the past three years?*
- Yes
- No
#1
Location*
Date*
MM slash DD slash YYYY
Charge*
Penalty*
#2
Location
Date
MM slash DD slash YYYY
Charge
Penalty
#3
Location
Date
MM slash DD slash YYYY
Charge
Penalty
Have you been involved in more than these three traffic convictions or forfeitures in the past three years?*
- Yes
- No

EXPERIENCE AND QUALIFICATIONS - DRIVER

Driver licenses or permits held in the past 3 years
#1
State*
State
License No.*
Class*
Endorsement(s)*
Expiration Date*
MM slash DD slash YYYY
#2
State
State
License No.
Class
Endorsement(s)
Expiration Date
MM slash DD slash YYYY
#3
State
State
License No.
Class
Endorsement(s)
Expiration Date
MM slash DD slash YYYY

A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*
- Yes
- No
B. Has any license, permit, or privilege ever been suspended or revoked?*
- Yes
- No
IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS*

DRIVING EXPERIENCE
STRAIGHT TRUCK*
- Yes
- No
Type of equipment*
- Van
- Truck
- Flat
- Dump
- Refer
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Approx. No. of Miles (Total)*

TRACTOR AND SEMI-TRAILER*
- Yes
- No
Type of equipment*
- Van
- Truck
- Flat
- Dump
- Refer
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Approx. No. of Miles (Total)*

TRACTOR - TWO TRAILERS*
- Yes
- No
Type of equipment*
- Van
- Truck
- Flat
- Dump
- Refer
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Approx. No. of Miles (Total)*

TRACTOR - THREE TRAILERS*
- Yes
- No
Type of equipment*
- Van
- Truck
- Flat
- Dump
- Refer
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Approx. No. of Miles (Total)*

MOTORCOACH - SCHOOL BUS (More than 8 passengers.)*
- Yes
- No
Type of equipment*
- Van
- Truck
- Flat
- Dump
- Refer
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Approx. No. of Miles (Total)*

MOTORCOACH - SCHOOL BUS (More than 15 passengers.)*
- Yes
- No
Type of equipment*
- Van
- Truck
- Flat
- Dump
- Refer
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Approx. No. of Miles (Total)*

Other types of equipment driven?
LIST STATES OPERATED IN FOR THE LAST FIVE YEARS:*
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

EXPERIENCE AND QUALIFICATIONS - OTHER
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)

Step 1 of 28

TO BE READ AND SIGNED BY APPLICANT

APPLICANT TO COMPLETE

List your addresses of residency for the past three years.

Dates

EMPLOYMENT HISTORY

Employer #1

Employer #2

Employer #3

Employer #4

Employer #5

Employer #6

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE

Accident #2

Accident #3

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

#1

#2

#3

EXPERIENCE AND QUALIFICATIONS - DRIVER

#1

#2

#3

DRIVING EXPERIENCE

EXPERIENCE AND QUALIFICATIONS - OTHER

TO BE READ AND SIGNED BY APPLICANT

APPLICATION FORM WAIVER

EEO SURVEY

This information is for compliance reporting only. It will be removed from your application prior to review. It is not considered in the employment process.