Join Our Team "*" indicates required fields Applicant Name* Date of Application MM slash DD slash YYYY Company Address Street City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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 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 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. Signature Date MM slash DD slash YYYY Applicant to Complete (Answer All Questions - Please Print)Position(s) Applied for Name First Middle Last Social Security No. List Your Addresses of Residency for The Past 3 Years.Current Address Street City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneHow Long? Previous Address Street City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Long? Do You Have the Legal Right to Work in the United States? Date of Birth MM slash DD slash YYYY (Required for Commerical Drivers)Can You Provide Proof of Age?Max. file size: 100 MB.Have You Worked for This Company Before? Where? From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Rate of Pay Position Reason for Leaving Are You Now Employed? If Not, how Long Since Leaving Last Employment? Who Referred You? Rate of Pay Expected Have You Ever Been Bonded? (Answer only If a Job Requirement)Name of Bonding Company 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]? if Yes, Explain if You Wish. Employment History All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding 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. Add another sheet as necessary.)EmployerName Address Street City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person Phone NumberFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Position Held Salary/Wage Reason for Leaving Were You Subject to The FMCSRs†While Employed? Yes No Was Your Job Desia Was Your Job Designated as A Safety-Sensitive Function in Any Dot-Regulated Mode Subject to The Drug and Alcohol Testing Requirements of 49 Cfr Part 40?gnated as A Safety-Sensitive Function in Any Dot-Regulated Mode Subject to The Drug and Alcohol Testing Requirements of 49 CFR Part 40? Yes No Employment History (Continued) All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding 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. Add another sheet as necessary.)EmployerName Address Street City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person Phone NumberDate MM slash DD slash YYYY Date MM slash DD slash YYYY Position Held Salary/Wage 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 CFR Part 40? Yes No EmployerName Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person Phone NumberDate MM slash DD slash YYYY Date MM slash DD slash YYYY Position Held Salary/Wage 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 CFR 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 8 or more 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 (attach Sheet if More Space Is Needed) if None, Write NoneLast AccidentDate MM slash DD slash YYYY Nature of Accident (Head-On, Rear-End, Upset, Etc.) Fatalities Injuries Hazardous Material Spill Next PreviousDate MM slash DD slash YYYY Nature of Accident (Head-On, Rear-End, Upset, Etc.) Fatalities Injuries Hazardous Material Spill Next PreviousDate MM slash DD slash YYYY Nature of Accident (Head-On, Rear-End, Upset, Etc.) Fatalities Injuries Hazardous Material Spill Traffic Convictions and Forfeitures for The Last Years (other than Parking Violations) if None, Write NoneLocation Date MM slash DD slash YYYY Charge Penalty Experience and Qualifications - DriverDriver Licenses or Permits Held in The Last YearsState Class Endorsement(S) Expiration Date MM slash DD slash YYYY 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 DetailsDriving Experience Check Yes or NoClass of Equipment - Straight Truck Yes No Type of Equipment Van Tank Flat Dump Refer From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Approx. No. of Miles Class of Equipment - Tractor and Semi-Trailer Yes No Type of Equipment Van Tank Flat Dump Refer From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Approx. No. of Miles Class of Equipment - Tractor - Two Trailers Yes No Type of Equipment Van Tank Flat Dump Refer From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Approx. No. of Miles Class of Equipment - Tractor - Three Trailers Yes No Type of Equipment Van Tank Flat Dump Refer From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Approx. No. of Miles Class of Equipment - Motorcoach - School Bus Yes No More than 8 PassengersClass of Equipment - Motorcoach - School Bus Yes No More than 15 PassengersFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Approx. No. of Miles Other List States Operated in For the Last Five Years Show Special Courses or Training that Will Help You as A Driver List Courses and Training Other than Shown Elsewhere in This Application Which Safe Driving Awards Do You Hold and From Whom? Experience and Qualifications - OtherShow Any Trucking, Transportation or Other Experience that May Help in Your Work for This Company List Special Equipment or Technical Materials You Can Work With (Other than Those Already Shown) EducationCircle 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.Signature Date MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
