Driver Application APPLICANT INFORMATIONName(Required) First Middle Last Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY SOCIAL SECURITY #(Required)Date of Application(Required) MM slash DD slash YYYY Date Available for Work MM slash DD slash YYYY Position Applied for(Required)Do you have legal right to work in the United States?(Required) Yes No PREVIOUS THREE YEARS RESIDENCYCurrentStreetCityStateZip# of Years at AddressMailingStreetCityStateZip# of Years at AddressPreviousStreetCityStateZip# of Years at Address Add Removeuse the right side ( + ) and ( - ) to add/remove itemsLICENSE INFORMATION No person who operates a commercial motor 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.Current LicenseStateLicenseType/ClassEndorsementsExpiration DatePreviously Held Current LicensesStateLicenseType/ClassEndorsementsExpiration Date Add Removeuse the right side ( + ) and ( - ) to add/remove itemsDRIVING EXPERIENCEDriving ExperienceClass of EquipmentType of Equipment (Van, Tank, Flat, Etc.)Date FromDate ToApprox # of Miles (Total) Add Removeuse the right side ( + ) and ( - ) to add/remove itemsACCIDENT RECORD FOR THE PAST 3 YEARSDriving ExperienceDates (List Most Recent First)Nature Of Accident (Head-on, Rear-end, Upset, Etc.)# Fatalities# InjuriesChemical Spills (Y/n) Add Removeuse the right side ( + ) and ( - ) to add/remove itemsTRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)Driving ExperienceDate Convicted (Month/year)Violation (I.e. Dui, Dwi, Open Container, etc)State Of ViolationPenalty (Forfeited Bond, Collateral And/or Points) Add Removeuse the right side ( + ) and ( - ) to add/remove itemsHas any license, permit, or privilege ever been suspended or revoked? Yes No ExplainHave you ever been convicted of a felony or misdemeanor? Yes No ExplainHas any license, permit, or privilege ever been suspended or revoked? Yes No ExplainEMPLOYMENT 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) EMPLOYERNamePhoneAddress Street Address Position heldDate From MM slash DD slash YYYY Date To MM slash DD slash YYYY Reason for LeavingSalaryExplain Any Gaps In Employment (Include Month/year & Reason)While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No 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 No SECOND (MOST RECENT) EMPLOYERNamePhoneAddress Street Address Position heldDate From MM slash DD slash YYYY Date To MM slash DD slash YYYY Reason for LeavingSalaryExplain Any Gaps In Employment (Include Month/year & Reason)While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No 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 No THIRD (MOST RECENT) EMPLOYERNamePhoneAddress Street Address Position heldDate From MM slash DD slash YYYY Date To MM slash DD slash YYYY Reason for LeavingSalaryExplain Any Gaps In Employment (Include Month/year & Reason)While employed here, were you subject to the Federal Motor Carrier Safety Regulations? Yes No 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 No EDUCATIONDriving ExperienceSchoolName & LocationCourse Of StudyYears CompletedGraduate (Y/n)Details Add Removeuse the right side ( + ) and ( - ) to add/remove itemsOTHER QUALIFICATIONSPlease 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 (printed)(Required) First Last Date(Required) MM slash DD slash YYYY Applicant Signature(Required) Δ
