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Driver's Application For Employment

Applicant Name
Social Security No
Phone Number
Company
Address
City    State    Zip 
 
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 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 that 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.
I Agree
 

APPLICANT TO COMPLETE
(answer all questions please)
Position(s) Applied for


List your addresses of residency for the past 3 years.
Current Address Street    City 
State    Zip    Phone    How Long?(yr./mo.) 
Previous Addresses Street    City 
State    Zip    How Long?(yr./mo.) 
Street    City 
State    Zip    How Long?(yr./mo.) 
Street    City 
State    Zip    How Long?(yr./mo.) 
 
Do you have the legal right to work in the United States?
Date of Birth(Required for Commercial Drivers) Can you provide proof of age?
Have you worked for this company before? Where?
Dates: From To Rate of Pay Position
Reason for leaving?
Are you now employed? if not, how long since last employment?
Who referred you? Rate of pay expected
Have you ever been bonded? Name of bonding company
Have you ever been convicted of a felony?
If yes, please explain fully. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.
Can you perform the requirements of the position, as described to you, with or without a reasonable accommodation?
if no, 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 DATE
Name  From(mo/yr)  To(mo/yr) 
Address  Position Held 
City   State   Zip    Salary/Wage 
Contact Person   Phone Number  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 CRF PART 40?   YES    NO
EMPLOYER DATE
Name  From(mo/yr)  To(mo/yr) 
Address  Position Held 
City   State   Zip    Salary/Wage 
Contact Person   Phone Number  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 CRF PART 40?   YES    NO
EMPLOYER DATE
Name  From(mo/yr)  To(mo/yr) 
Address  Position Held 
City   State   Zip    Salary/Wage 
Contact Person   Phone Number  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 CRF PART 40?   YES    NO
EMPLOYER DATE
Name  From(mo/yr)  To(mo/yr) 
Address  Position Held 
City   State   Zip    Salary/Wage 
Contact Person   Phone Number  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 CRF PART 40?   YES    NO
EMPLOYER DATE
Name  From(mo/yr)  To(mo/yr) 
Address  Position Held 
City   State   Zip    Salary/Wage 
Contact Person   Phone Number  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 CRF PART 40?   YES    NO
EMPLOYER DATE
Name  From(mo/yr)  To(mo/yr) 
Address  Position Held 
City   State   Zip    Salary/Wage 
Contact Person   Phone Number  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 CRF 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 more than 8 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 (IF NONE, WRITE NONE)
DATES NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES HAZARDOUS MATERIAL SPILL
LAST ACCIDENT 
NEXT PREVIOUS 
NEXT PREVIOUS 


TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
LOCATION DATE CHARGE PENALTY
 

EXPERIENCE AND QUALIFICATIONS - DRIVER
LIST ALL DRIVER LICENSES OR PERMITS HELD IN THE PAST 3 YEARS
DRIVER LICENSES STATE LICENSE NO. TYPE EXPIRATION DATE
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 CHECK YES OR NO
CLASS OF EQUIPMENT TYPE OF EQUIPMENT DATE
FROM(M/Y)  TO(M/Y) 		APPROX. NO. OF MILES (TOTAL)
STRAIGHT TRUCK  YES    NO  VAN    TANK    FLAT    DUMP    REEFER
TRACTOR AND SEMI-TRAILER  YES    NO  VAN    TANK    FLAT    DUMP    REEFER
TRACTOR - TWO TRAILERS  YES    NO  VAN    TANK    FLAT    DUMP    REEFER
TRACTOR - THREE TRAILERS  YES    NO  VAN    TANK    FLAT    DUMP    REEFER
MOTORCOACH - SCHOOL BUS(More than 8 passengers)  YES    NO -
MOTORCOACH - SCHOOL BUS(More than 16 passengers)  YES    NO -
OTHER 
LIST STATES OPERATED IN FOR LAST FIVE YEARS:
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS 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)
 

EDUCATION
HIGHEST GRADE COMPLETED:  1    2    3    4    5    6    7    8  
HIGH SCHOOL:  1    2    3    4  
COLLEGE:  1    2    3    4  
LAST SCHOOL ATTENDED: Name   City   State   
 

TO BE READ AND SIGNED BY APPLICANT
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 Agree
 
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