Employment Application Form

Name*

Date*

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, non-job related disability, or any other protected group status.

TO BE READ AND SIGNED BY APPLICANT I authorize you to make such investigations and inquiries 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 regarding 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 performances history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: - Review information provided by my previous employers. - Have errors in the information corrected 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.

Signature*

Date*

Name*

SSN*

Current Address*

Address for past three years*

Phone Number*

Date*

Name of person to notify in case of emergency*

Phone Number*

Relationship*

Position applying for*

Salary desired*

Do you have the legal right to work in the United States?

Yes
No

Have you ever worked for this company before?*

Yes
No

Untitled

When?*

Are you now employed?*

Yes
No

Untitled

Who referred you?*

If no, how long since leaving last employment?*

Have you ever been bonded?*

Yes
No

Name of bonding company*

Highest educational level reached*

List last school attended*

Please list all tickets you have received in the past three years:

Date

Charge

Location

Penalty

Date

Charge

Location

Penalty

Date

Charge

Location

Penalty

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

Yes
No

Have you ever been denied a license, permit or privilege to operate a vehicle?

Yes
No

If yes to either, please explain.

Current Driver’s license:

State of issue*

License number*

Expiration date*

List all states that you have held licenses in during the past 3 years

State of issue

License number

State of issue

License number

State of issue

License number

List all states that you have operated in during the last 5 years

Show special courses or training that will help you as a driver.

Which safe driving awards do you hold and from whom

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 material you can work with (other than those already shown)

List all driving experience

Straight truck:

From Date*

To Date*

Tractor trailer:

From Date*

To Date*

Do you have experience with the following? If so, please list dates.

Do you have experience with the following?

Yes
No

Ten-Wheeler

End Dump

Bottom Dump

Bottom Dump Trains

Water Truck

Transfers

Heavy Haul

Have you ever been convicted of a felony?*

Yes
No

If so, please list charge and date.*

Do you use any form of drugs or narcotics that could interfere with your ability to operate a commercial motor vehicle safely?*

Yes
No

Have you ever served in the military?*

Yes
No

If yes, please list dates and branch of service.*

Have you attended any truck driving training schools?*

Yes
No

If yes, please list dates and names.*

Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the attached job description)?*

Yes
No

If yes, explain if you wish.*

Past 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 interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle. List employers in reverse order staring with the most recent. Add another sheet as necessary.

#Includes vehicles having a VWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, 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 VCWR of 10,001 lbs. or more, (2) is designed or used to transport 9 or more passengers, or (3) is of any size and is used to transport hazardous material in a quantity requiring placarding.

Employer

Phone Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Supervisor

Employed From

To

Position Held

Salary

Reason for Leaving

Were you subject to the FMCSR’s++ while employed?

Was your job designated as a safety-sensitive function in any way DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Employer

Phone number

Address

Street Address City State / Province / Region ZIP / Postal Code

Supervisor

Employed From*

To

Position Held

Salary

Reason for Leaving

Were you subject to the FMCSR’s++ while employed?

Was your job designated as a safety-sensitive function in any way DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Employer

Phone Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Supervisor

Employed From

To

Position Held

Salary

Reason for Leaving

Were you subject to the FMCSR’s++ while employed?

Was your job designated as a safety-sensitive function in any way DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Employer

Phone number

Address

Street Address City State / Province / Region ZIP / Postal Code

Supervisor

Employed From

To

Position Held

Salary

Reason for Leaving

Were you subject to the FMCSR’s++ while employed?

Was your job designated as a safety-sensitive function in any way DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Employer

Phone number

Address

Street Address City State / Province / Region ZIP / Postal Code

Supervisor

Employed From

To

Position Held

Salary

Reason for Leaving

Were you subject to the FMCSR’s++ while employed?

Was your job designated as a safety-sensitive function in any way DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Employer

Phone number

Address

Street Address City State / Province / Region ZIP / Postal Code

Supervisor

Employed From

To

Position Held

Salary

Reason for Leaving

Were you subject to the FMCSR’s++ while employed?

Was your job designated as a safety-sensitive function in any way DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Employer

Phone number

Address

Street Address City State / Province / Region ZIP / Postal Code

Supervisor

Employed From

To

Position Held

Salary

Reason for Leaving

Were you subject to the FMCSR’s++ while employed?

Was your job designated as a safety-sensitive function in any way DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

I hereby certify that the above information is true and correct to the best of my knowledge. I understand that any falsified, misleading, or untrue statements will result in my not being granted a safety clearance. I also understand that if at any future date any of the above information is deemed to be false, that my safety clearance may be revoked at that time. By my signature below, I grant permission for the company that I am applying with permission to investigate my background and past employment.

Employment Form

Please list all tickets you have received in the past three years:

Current Driver’s license:

List all states that you have held licenses in during the past 3 years

List all driving experience

Do you have experience with the following? If so, please list dates.

Past Employment History