DRIVER EMPLOYMENT APPLICATIONCOMPLETE IN FULL OR IT WILL NOT BE CONSIDEREDAPPLICANT INFORMATIONFirst NameField is required!Middle NameField is required!Last NameField is required!Your Phone NumberEnter Your Phone NumberDate of BirthEnter Date of BirthYour E-mail AddressField is required!Social Security Number LAST 4 DIGITSEnter Social Security NumberDate of ApplicationEnter Date of ApplicationPosition Applied ForField is required!Date Available For WorkEnter Date Available For WorkDo you have legal right to work in the United States?YesNoEnter if you have Legal Rights in the US?PREVIOUS THREE YEARS RESIDENCYAttach additional sheet if more space is neededCURRENT STREETEnter Current Street You LiveMAILING ADDRESSEnter Mailing AddressPREVIOUS STREET #1Enter Previous Street #1PREVIOUS STREET #2Enter Previous Street #2PREVIOUS STREET #3Enter Previous Street #3CURRENT CITYEnter Current CityMAILING CITYEnter Mailing CityPREVIOUS CITY #1Enter Previous City #1PREVIOUS CITY #2Enter Previous City #2PREVIOUS CITY #3Enter Previous City #3CURRENT STATEEnter Current StateMAILING STATEEnter Mailing StatePREVIOUS STATE #1Enter Previous State #1PREVIOUS STATE #2Enter Previous State #2PREVIOUS STATE #3Enter Previous State #3CURRENT ZIP CODEEnter Current Zip CodeMAILING ZIP CODEEnter Mailing Zip CodePREVIOUS ZIP CODE #1Enter Previous Zip Code #1PREVIOUS ZIP CODE #2Enter Previous Zip Code #2PREVIOUS ZIP CODE #3Enter Previous Zip Code #3YRS AT CURRENT ADDREnter Years At Current AddressYRS AT CURRENT ADDREnter Years Using Mailing AddressYRS AT CURRENT ADDR #1Enter Years At Previous Address #1YRS AT CURRENT ADDR #2Enter Years At Previous Address #2YRS AT CURRENT ADDR #3Enter Years At Previous Address #3LICENSE INFORMATIONNo person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). 1 certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.CURRENT DL STATE- select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingEnter Current StateCURRENT DRIVERS LICENSEEnter Drivers License NumberCURRENT DL TYPE/CLASSEnter Current DL Type/ClassDL CURRENT ENDORSEMENTSEnter DL Current EndorsementsDL EXPIRATION DATEEnter DL Expiration DatePREVIOUSLY HELD LICENSESPREVIOUS DL STATE #1- select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingEnter Previous DL State #1PREVIOUS DL STATE #2- select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingEnter Previous DL State #2PREVIOUS DL NUMBER #1Enter Previous DL Number #1PREVIOUS DL NUMBER #2Enter Previous DL Number #2PREVIOUS DL TYPE/CLASS #1Enter Previous DL Type/Class #1PREVIOUS DL TYPE/CLASS #2Enter Previous DL Type/Class #2PREV DL ENDORSEMENTS #1Enter Previous DL Endorsements #1PREV DL ENDORSEMENTS #2Enter Previous DL Endorsements #2PREVIOUS DL EXPIRATION #1Enter Previous DL Expiration Date #1PREVIOUS DL EXPIRATION #2Enter Previous DL Expiration Date #2DRIVING EXPERIENCECLASS OF EQUIPMENTSTRAIGHT TRUCKTRAVCTOR & SEMI-TRAILERTRACTOR & 2 TRAILERSTRACTOR & TANKEROTHEREQUIP (VAN, TANK, FLAT, ETC)TYPE OF EQUIPMENT #1Field is required!TYPE OF EQUIPMENT #2Field is required!TYPE OF EQUIPMENT #3Field is required!TYPE OF EQUIPMENT #4Field is required!TYPE OF EQUIPMENT #5Field is required!DATE FROMDATE FROM #1Field is required!DATE FROM #2Field is required!DATE FROM #3Field is required!DATE FROM #4Field is required!DATE FROM #5Field is required!DATE TODATE TO #1Field is required!DATE TO #2Field is required!DATE TO #3Field is required!DATE TO #4Field is required!DATE TO #5Field is required!APPROX# OF MILES (TOTAL)APPRX# MILES #1Field is required!APPRX# MILES #2Field is required!APPRX# MILES #3Field is required!APPRX# MILES #1Field is required!APPRX# MILES #1Field is required!ACCIDENT RECORD FOR THE PAST 3 YEARSChoose YES for additional sheet needed. Choose NO if this section does not applyYESNO Please chooseDATES (List most recent first)DATE LIST MOST RECENT ACC #1Field is required!DATE LIST MOST RECENT ACC #2Field is required!DATE LIST MOST RECENT ACC #3Field is required!ACC Type(Head-on, Rear-in)NATURE OF ACC #1Field is required!NATURE OF ACC #2Field is required!NATURE OF ACC #3Field is required!# FATALITIES# FATALITIES #1Field is required!# FATALITIES #2Field is required!# FATALITIES #3Field is required!# INJURIES# INJURIES #1Field is required!# INJURIES #2Field is required!# INJURIES #3Field is required!CHEMICAL SPILLS (Y/N)CHEMICAL SPILLS (Y/N) #1Field is required!CHEMICAL SPILLS (Y/N) #2Field is required!CHEMICAL SPILLS (Y/N) #3Field is required!TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)Choose YES for additional sheet needed. Choose NO if this section does not applyYESNO Please chooseDATE CONVICTED (Mo/Yr) DATE CONVICTED #1Field is required!DATE CONVICTED #2Field is required!DATE CONVICTED #3Field is required!VIOLATIONVIOLATION #1Field is required!VIOLATION #2Field is required!VIOLATION #3Field is required!STATE OF VIOLATIONSTATE OF VIOLATION #1Field is required!STATE OF VIOLATION #2Field is required!STATE OF VIOLATION #3Field is required!PENALTY (Forfeited bond, collateral and/or points)PENALTY (Forfeited bond, collateral and/or points) #1Field is required!PENALTY (Forfeited bond, collateral and/or points) #2Field is required!PENALTY (Forfeited bond, collateral and/or points) #3Field is required!Have you ever been denied a license, permit, or privilege to operate a motor vehicle?YESNOPlease answerIf yes, explain denied a license, permit, or privilege to operate a motor vehicle:Field is required!Has any license, permit, or privilege ever been suspended or revoked?YESNOPlease answerIf yes, explain license, permit, or privilege ever been suspended or revokedField is required!EMPLOYMENT HISTORYThe Federal Motor Carrier Safety Regulations (49 CFR 391.21) 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 in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.CURRENT (MOST RECENT) EMPLOYERNAMEField is required!PHONEField is required!ADDRESSField is required!POSITION HELDField is required!Field is required!Field is required!REASON FOR LEAVINGField is required!Field is required!EXPLAIN ANY GAPS IN EMPLOYMENT (include month/year & reason)Field is required!While employed here, were you subject to the Federal Motor Carrier Safety Regulations?YesNoPlease answerWas the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? YesNoPlease answerSECOND (MOST RECENT) EMPLOYERNAMEField is required!PHONEField is required!ADDRESSField is required!POSITION HELDField is required!Field is required!Field is required!REASON FOR LEAVINGField is required!Field is required!EXPLAIN ANY GAPS IN EMPLOYMENT (include month/year & reason)Field is required!While employed here, were you subject to the Federal Motor Carrier Safety Regulations?YesNoField is required!Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? YesNoField is required!THIRD (MOST RECENT) EMPLOYERNAMEField is required!PHONEField is required!ADDRESSField is required!POSITION HELDField is required!Field is required!Field is required!REASON FOR LEAVINGField is required!Field is required!EXPLAIN ANY GAPS IN EMPLOYMENT (include month/year & reason)Field is required!While employed here, were you subject to the Federal Motor Carrier Safety Regulations?YesNoField is required!Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? YesNoField is required!EDUCATIONSCHOOLHIGH SCHOOL GRADUTE?YESNOPlease answerCOLLEGE GRADUTE?YESNOPlease answerOTHER GRADUTE?YESNOPlease answerNAME & LOCATION NAME & LOCATION HIGH SCHOOLField is required!NAME & LOCATION COLLEGEField is required!NAME & LOCATION OTHERField is required!COURSE OF STUDYCOURSE OF STUDY HIGH SCHOOLField is required!COURSE OF STUDY COLLEGEField is required!COURSE OF STUDY OTHERField is required!YEARS COMPLETEDYEARS COMPLETED HIGH SCHOOL:Field is required!YEARS COMPLETED COLLEGEField is required!YEARS COMPLETED OTHERField is required!DETAILSDETAILS HIGH SCHOOLField is required!DETAILS COLLEGEField is required!DETAILS OTHERField is required!OTHER QUALIFICATIONSPlease list any other qualifications that you have and which you believe should be considered.Field is required!TO BE READ AND SIGNED BY APPLICANTI authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior 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. 1 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 resend 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. 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. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.APPLICANT SIGNATUREUpload SignatureUpload SignatureDATEChoose DateAPPLICANT (PRINTED)Please print nameCONFIRM INFO TO SENDInformation Valid and Box check also act as a signed documentCheck box to confirmation information to be sent to receiver <a href="http://britjen.com/howtos/video/HowToSaveSignature.mp4" target="_blank"><img decoding="async" alt="" src="http://britjen.com/images/content/HowToSaveSignature.png" width="300"></a><br /> <br /> <iframe src="https://nosbiz.com/signature/clients/driverprofile" width="800" height="473"></iframe>Submit
