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Commercial Driver Application
Company Name (if Owner Operator):
Company Street Address:
City | State | ZIP:
Applicant Name:
Home Phone:
Cell Phone:
*Current Address:
Street
City
State
ZIP
*If at the above residence less than three years, list below all residences for the past three years:
Street
City
State
ZIP
Street
City
State
ZIP
Position Applying for:
Temporary
Part Time
Full Time
Who Referred You?
Rate of Pay Expected?
Have you ever worked for this company before?
Yes
No
Dates: From
to
mm/yyyy
mm/yyyy
Where?
Rate of Pay:
Position:
Reason for Leaving:
Names of any any relatives employed by this company:
Are you currently employed?
Yes
No
If not, how long since leaving last employment?
EDUCATION
Select highest grade completed:
1
2
3
4
5
6
7
8
9
10
11
12
College:
1
2
3
4
Last school attended:
MILITARY EXPERIENCE
Have you ever served in the U.S. Armed Forces?
Yes
No
If yes, which branch of service:
Are you currently serving in Military Reserves?
Yes
No
Are you currently serving in National Guard?
Yes
No
GENERAL
Have you ever been bonded?
Yes
No
Name of bonding company:
(Answer only if a job requirement)
Have you ever been convicted of a felony?
Yes
No
*If yes, please explain:
*Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.
DRIVER EXPERIENCE AND QUALIFICATIONS
The Federal Motor Carrier Safety Regulations (49CFR391.21 (b) (2) requires that driver applicants state their date of birth and SS #.
Date of Birth:
Social Security Number:
mm/dd/yyyy
PHYSICAL HISTORY
The Federal Motor Carrier Safety Regulations (49CFR391 Subpart E) requires that all driver applicants pass certain physical tests before they are hired to drive a motor vehicle.
Date of last Department of Transportation prescribed examination:
Can you provide a copy?
Yes
No
Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, leg, hand, or arm?
Yes
No
ALCOHOL AND CONTROLLED SUBSTANCE STATEMENT
The Federal Motor Carrier Safety Regulations 49CFR40.25(j) requires all persons with applying for a driving position requiring a commercial drivers license to answer the following questions:
1) Within the last two years, have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work?
Yes
No
2) Within the last two years, have you ever tested positive, or refused to test, on any type of drug or alcohol test administered by an employer for which you performed safety-sensitive transportation work?
Yes
No
3) If you answered yes to either 1 or 2 above, can you provide and/or obtain proof that you have successfully completed the DOT return-to-duty requirements?
Yes
No
Applicant's Signature:
Date:
mm/dd/yyyy
DRIVING LICENSE INFORMATION
Driver Licenses held in the past 3 years must be shown:
State
License Number
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
C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?
Yes
No
DRIVING EXPERIENCE
Class of Equipment
Type of Equipment (Van, Tank, Flat, etc.)
How long?
Approximate Total Miles
Straight Truck
Tractor and Semi-Trailer
Twin
Other
List states operated in during the last five years:
List special courses or training that will help you as a driver:
List safe driving awards and who awards were presented by:
ACCIDENT HISTORY
Accident Review for the past 3 years
Date (mmddyyyy)
Nature of Accident (Head-on, Rear-End, Upset, etc.)
# Fatalities
# Injuries
# Vehicles Towed
Citation Issued?
MOTOR VEHICLE DRIVING RECORD (MVR)
Traffic Convictions and Forfeitures for the past 3 years other than parking violations.
Date (mmddyyyy)
Location
Charge
Penalty
EMPLOYMENT RECORD
The Federal Motor Carrier Safety Regulations (49CFR391.21) 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 must be explained.
Start with the LAST or CURRENT position, including any military experience, and work back. You are required to list the complete mailing address: Street number, city, state, and zip code.
Current Employer:
Supervisor's name:
Address:
Phone:
Position Held:
From (mmyyyy)
To (mmyyyy)
Salary:
Reason for leaving:
Previous Employer:
Supervisor's name:
Address:
Phone:
Position Held:
From (mmyyyy)
To (mmyyyy)
Salary:
Reason for leaving:
Previous Employer:
Supervisor's name:
Address:
Phone:
Position Held:
From (mmyyyy)
To (mmyyyy)
Salary:
Reason for leaving:
Previous Employer:
Supervisor's name:
Address:
Phone:
Position Held:
From (mmyyyy)
To (mmyyyy)
Salary:
Reason for leaving:
Previous Employer:
Supervisor's name:
Address:
Phone:
Position Held:
From (mmyyyy)
To (mmyyyy)
Salary:
Reason for leaving:
Previous Employer:
Supervisor's name:
Address:
Phone:
Position Held:
From (mmyyyy)
To (mmyyyy)
Salary:
Reason for leaving:
APPLICANT MUST READ AND SIGN
I certify that I have read and understand all of this employment application. It is agreed and understood that the employer or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and other persons named herein from all liability for any damages on account of his furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks that are pertinent to the job.
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 investigative Consumer Report, including information regarding my character, personal 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 employment file.
I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.
If hired, I agree to abide by all the rules and policies of the employer.
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.
Applicant's Signature:
Date:
mmddyyyy
Thank you! Your submission has been received!
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