Application For Employment

Company

Street Address

City, State and Zip Code

Applicant Information

Name *

First

Middle

Last

Street Address *

City, State and Zip Code *

Date of Birth *

Telephone Number *

E-Mail Address *

Previous Three Years Residency

Street, City, State and ZipCode

Number of Years

Street, City, State and ZipCode

Number of Years

Street, City, State and ZipCode

Number of Years

License Information

Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below

State

License Number

Type

Expiration Date

Driving Experience: Class of Equipment - Straight Truck

Type Of Equipment (Van, Tank, Flat, Etc..)

From

To

Approx. No. of Miles (Total)

Driving Experience: Class of Equipment - Tractor and Semi-Trailer

Type Of Equipment (Van, Tank, Flat, Etc..)

From

To

Approx. No. of Miles (Total)

Driving Experience: Class of Equipment - Tractor - Two Trailers

Type Of Equipment (Van, Tank, Flat, Etc..)

From

To

Approx. No. of Miles (Total)

Driving Experience: Class of Equipment -Other

Type Of Equipment (Van, Tank, Flat, Etc..)

From

To

Approx. No. of Miles (Total)

Accident Record for Past 3 Years or More

Dates

Nature of Accident ( Head-On, Rear-End, Upset, Etc..)

Number of Fatalities

Number Injuries

Chemical Spills

Yes No

Dates

Nature of Accident ( Head-On, Rear-End, Upset, Etc..)

Number of Fatalities

Number Injuries

Chemical Spills

Yes No

Traffic Convictions and Forfeitures for the Past 3 Years

Date Convicted

Violation

State of Violation

Penalty (forfeited bond, collateral and/or points)

Date Convicted

Violation

State of Violation

Penalty (forfeited bond, collateral and/or points)

Date Convicted

Violation

State of Violation

Penalty (forfeited bond, collateral and/or points)

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? *

Yes No

If yes, explain

B. Has any license, permit or privilege ever been suspended or revoked? *

Yes No

If yes, explain

Employment Record

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record)

Last Employer: Name

Street Address

Phone

Position Held

From

To

Salary

Reasons for Leaving

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? *

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? *

Yes No

Second Last Employer: Name

Street Address

City, State and Zip Code

Phone

Position Held

From

To

Reasons for Leaving

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes No

Third Last Employer: Name

Street Address

City, State and Zip Code

Position Held

From

To

Salary

Reasons for Leaving

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes No

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make sure investigations and inquiries to 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 current/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.”

Date / Time

Applicant's Initials

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.

Date / Time

Applicant's Initials

Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.