Driver Application

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 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."
Name*
First Middle Last
Social Security Number
Phone*
Date Of Birth*
Date Format: MM slash DD slash YYYY
Hire Date
Date Format: MM slash DD slash YYYY
Address*
Street Address City State ZIP Code

Employment History
All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record). You are required to list the complete mailing address: street number and name city, state and zip code.
Current or last employer:
Employer Name
Phone
Address
Street Address City State ZIP Code
Reason For Leaving
Second last employer:
Employer Name
Phone
Address
Street Address City State ZIP Code
Reason For Leaving
Third last employer:
Employer Name
Phone
Address
Street Address City State ZIP Code
*Any gaps in employment and/or unemployment must be explained. **The Federal Motor Carrier Safety Regulations 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) for compensation; or (3) is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Experience and Qualification
- If no driving experience in the last 3 years check here
Class of Equipment
Select all that apply (Ctrl Click to select multiple)
Type of Equipment
Select all that apply (Ctrl Click to select multiple)

Accident History
- If no accidents in the last 3 years check here
Date of Accident
Date Format: MM slash DD slash YYYY
Nature of Accident
# of Fatalities
# of Injuries
Hazardous Materials Spill?
- Yes
- No
Date of Accident
Date Format: MM slash DD slash YYYY
Nature of Accident
# of Fatalities
# of Injuries
Hazardous Materials Spill?
- Yes
- No
Date of Accident
Date Format: MM slash DD slash YYYY
Nature of Accident
# of Fatalities
# of Injuries
Hazardous Materials Spill?
- Yes
- No
Traffic Convictions and Forfeitures (3 Years)
Date Convicted
Date Format: MM slash DD slash YYYY
Violation (not including parking violations)
State of Violation
Penalty
Date Convicted
Date Format: MM slash DD slash YYYY
Violation (not including parking violations)
State of Violation
Penalty

License Information
Section 383.21 FMCSR states "No person who operates a commercial vehicle shall at any time have more than one drivers license". I certify that I do not have any more than one motor vehicle license, the information for which is listed below.
State
License Number
Experation Date
Date Format: MM slash DD slash YYYY
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
- Yes
- No
If yes, give details
B. Has any license, permit or privilege ever been suspended or revoked?
- Yes
- No
If yes, give details
Application Certification
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.
Type Your Full Name
Date
Date Format: MM slash DD slash YYYY

Driver Application

Step 1 of 5

TO BE READ AND SIGNED BY APPLICANT

Employment History

Current or last employer:

Second last employer:

Third last employer:

Experience and Qualification

Accident History

Traffic Convictions and Forfeitures (3 Years)

License Information

Application Certification