Commercial Driver Application

APPLICANT INFORMATION

Date*

Position applying for*

Contractor

Driver

Contractor’s Driver

Plant

Name*

Phone*

Emergency Phone*

Age*

Date of Birth*

SS#*

Physical Exam Expiration Date*

Current & Previous Three Years Addresses

Address*

From

Address*

From

Address*

From

Have You Worked For This Company Before?*

Yes

From

Reason for leaving?

EDUCATION HISTORY

Please circle the highest grade completed

Grade school*

College

Post Graduate

EMPLOYMENT HISTORY

Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years.

Employment History

From (Mo/Yr)

To (Mo/Yr)

Name (Present or Last Employer)

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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

Employment History

From (Mo/Yr)

To (Mo/Yr)

Name (Present or Last Employer)

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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

Employment History

From (Mo/Yr)

To (Mo/Yr)

Name (Present or Last Employer)

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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

Employment History

From (Mo/Yr)

To (Mo/Yr)

Name (Present or Last Employer)

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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

Employment History

From (Mo/Yr)

To (Mo/Yr)

Name (Present or Last Employer)

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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

Employment History

From (Mo/Yr)

To (Mo/Yr)

Name (Present or Last Employer)

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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

Employment History

From (Mo/Yr)

To (Mo/Yr)

Name (Present or Last Employer)

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?

Yes

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

DRIVING EXPERIENCE

Class of Equipment

From

Approximate Number of Miles

Tractor & Semitrailer

Tractor & Semitrailer From

Tractor & Semitrailer To

Approximate Number of Miles

Tractor & two trailers

Tractor & two trailers From

Tractor & two trailers To

Approximate Number of Miles

Tractor & triple trailers

Tractor & triple trailers From

Tractor & triple trailers To

Approximate Number of Miles

Straight Truck

Straight Truck From

Straight Truck To

Approximate Number of Miles

Other

From

Approximate Number of Miles

List states operated in, for the last five (5) years

List special courses/training completed (PTD/DDC, HAZMAT, ETC)

List any Safe Driving Awards you hold and from whom

Accident Record for past three (3) years

Date of Accident

Nature of Accidents

Location of Accident

# of Fatalities

# of People Injured

Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations)

Date

Location

Charge

Penalty

Driver’s License (list each driver’s license held in the past three(3) years

State

License

Type

Endorsements

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

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

Have you ever been convicted of a felony?*

Yes

Give details

Job References

List three (3) persons for references, other than family members, who have knowledge of your safety habits

Name*

Address*

Phone*

Name*

Address*

Phone*

Name*

Address*

Phone*

To Be Read and Signed by Applicant

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

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.

Applicant Signature*

Date*