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Employment Application

COMPLETE IN FULL OR IT WILL NOT BE CONSIDERED

APPLICANT INFORMATION

First Name
Field is required!
Middle Name
Field is required!
Last Name
Field is required!
Your Phone Number
Enter Your Phone Number
Date of Birth
Enter Date of Birth
Your E-mail Address
Field is required!
Social Security Number LAST 4 DIGITS
Enter Social Security Number
Date of Application
Enter Date of Application
Position Applied For
Field is required!
Date Available For Work
Enter Date Available For Work
Do you have legal right to work in the United States?
Enter if you have Legal Rights in the US?

PREVIOUS THREE YEARS RESIDENCY

Attach additional sheet if more space is needed
CURRENT STREET
Enter Current Street You Live
MAILING ADDRESS
Enter Mailing Address
PREVIOUS STREET #1
Enter Previous Street #1
PREVIOUS STREET #2
Enter Previous Street #2
PREVIOUS STREET #3
Enter Previous Street #3
CURRENT CITY
Enter Current City
MAILING CITY
Enter Mailing City
PREVIOUS CITY #1
Enter Previous City #1
PREVIOUS CITY #2
Enter Previous City #2
PREVIOUS CITY #3
Enter Previous City #3
CURRENT STATE
Enter Current State
MAILING STATE
Enter Mailing State
PREVIOUS STATE #1
Enter Previous State #1
PREVIOUS STATE #2
Enter Previous State #2
PREVIOUS STATE #3
Enter Previous State #3
CURRENT ZIP CODE
Enter Current Zip Code
MAILING ZIP CODE
Enter Mailing Zip Code
PREVIOUS ZIP CODE #1
Enter Previous Zip Code #1
PREVIOUS ZIP CODE #2
Enter Previous Zip Code #2
PREVIOUS ZIP CODE #3
Enter Previous Zip Code #3
YRS AT CURRENT ADDR
Enter Years At Current Address
YRS AT CURRENT ADDR
Enter Years Using Mailing Address
YRS AT CURRENT ADDR #1
Enter Years At Previous Address #1
YRS AT CURRENT ADDR #2
Enter Years At Previous Address #2
YRS AT CURRENT ADDR #3
Enter Years At Previous Address #3

LICENSE INFORMATION

No 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 -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
Enter Current State
CURRENT DRIVERS LICENSE
Enter Drivers License Number
CURRENT DL TYPE/CLASS
Enter Current DL Type/Class
DL CURRENT ENDORSEMENTS
Enter DL Current Endorsements
DL EXPIRATION DATE
Enter DL Expiration Date
PREVIOUSLY HELD LICENSES
PREVIOUS DL STATE #1
  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
Enter Previous DL State #1
PREVIOUS DL STATE #2
  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
Enter Previous DL State #2
PREVIOUS DL NUMBER #1
Enter Previous DL Number #1
PREVIOUS DL NUMBER #2
Enter Previous DL Number #2
PREVIOUS DL TYPE/CLASS #1
Enter Previous DL Type/Class #1
PREVIOUS DL TYPE/CLASS #2
Enter Previous DL Type/Class #2
PREV DL ENDORSEMENTS #1
Enter Previous DL Endorsements #1
PREV DL ENDORSEMENTS #2
Enter Previous DL Endorsements #2
PREVIOUS DL EXPIRATION #1
Enter Previous DL Expiration Date #1
PREVIOUS DL EXPIRATION #2
Enter Previous DL Expiration Date #2

DRIVING EXPERIENCE

CLASS OF EQUIPMENT

STRAIGHT TRUCK

TRAVCTOR & SEMI-TRAILER

TRACTOR & 2 TRAILERS

TRACTOR & TANKER

OTHER

EQUIP (VAN, TANK, FLAT, ETC)

TYPE OF EQUIPMENT #1
Field is required!
TYPE OF EQUIPMENT #2
Field is required!
TYPE OF EQUIPMENT #3
Field is required!
TYPE OF EQUIPMENT #4
Field is required!
TYPE OF EQUIPMENT #5
Field is required!

DATE FROM

DATE FROM #1
Field is required!
DATE FROM #2
Field is required!
DATE FROM #3
Field is required!
DATE FROM #4
Field is required!
DATE FROM #5
Field is required!

DATE TO

DATE TO #1
Field is required!
DATE TO #2
Field is required!
DATE TO #3
Field is required!
DATE TO #4
Field is required!
DATE TO #5
Field is required!

APPROX# OF MILES (TOTAL)

APPRX# MILES #1
Field is required!
APPRX# MILES #2
Field is required!
APPRX# MILES #3
Field is required!
APPRX# MILES #1
Field is required!
APPRX# MILES #1
Field is required!

ACCIDENT RECORD FOR THE PAST 3 YEARS

Choose YES for additional sheet needed. Choose NO if this section does not apply
Please choose

DATES (List most recent first)

DATE LIST MOST RECENT ACC #1
Field is required!
DATE LIST MOST RECENT ACC #2
Field is required!
DATE LIST MOST RECENT ACC #3
Field is required!

ACC Type(Head-on, Rear-in)

NATURE OF ACC #1
Field is required!
NATURE OF ACC #2
Field is required!
NATURE OF ACC #3
Field is required!

# FATALITIES

# FATALITIES #1
Field is required!
# FATALITIES #2
Field is required!
# FATALITIES #3
Field is required!

# INJURIES

# INJURIES #1
Field is required!
# INJURIES #2
Field is required!
# INJURIES #3
Field is required!

CHEMICAL SPILLS (Y/N)

CHEMICAL SPILLS (Y/N) #1
Field is required!
CHEMICAL SPILLS (Y/N) #2
Field is required!
CHEMICAL SPILLS (Y/N) #3
Field 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 apply
Please choose

DATE CONVICTED (Mo/Yr)

DATE CONVICTED #1
Field is required!
DATE CONVICTED #2
Field is required!
DATE CONVICTED #3
Field is required!

VIOLATION

VIOLATION #1
Field is required!
VIOLATION #2
Field is required!
VIOLATION #3
Field is required!

STATE OF VIOLATION

STATE OF VIOLATION #1
Field is required!
STATE OF VIOLATION #2
Field is required!
STATE OF VIOLATION #3
Field is required!

PENALTY (Forfeited bond, collateral and/or points)

PENALTY (Forfeited bond, collateral and/or points) #1
Field is required!
PENALTY (Forfeited bond, collateral and/or points) #2
Field is required!
PENALTY (Forfeited bond, collateral and/or points) #3
Field is required!
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Please answer
If 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?
Please answer
If yes, explain license, permit, or privilege ever been suspended or revoked
Field is required!

EMPLOYMENT HISTORY

The 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) EMPLOYER

NAME

Field is required!

PHONE

Field is required!

ADDRESS

Field is required!

POSITION HELD

Field is required!
Field is required!
Field is required!

REASON FOR LEAVING

Field 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?
Please answer
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?
Please answer

SECOND (MOST RECENT) EMPLOYER

NAME

Field is required!

PHONE

Field is required!

ADDRESS

Field is required!

POSITION HELD

Field is required!
Field is required!
Field is required!

REASON FOR LEAVING

Field 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?
Field 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?
Field is required!

THIRD (MOST RECENT) EMPLOYER

NAME

Field is required!

PHONE

Field is required!

ADDRESS

Field is required!

POSITION HELD

Field is required!
Field is required!
Field is required!

REASON FOR LEAVING

Field 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?
Field 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?
Field is required!

EDUCATION

SCHOOL

HIGH SCHOOL GRADUTE?
Please answer
COLLEGE GRADUTE?
Please answer
OTHER GRADUTE?
Please answer

NAME & LOCATION

NAME & LOCATION HIGH SCHOOL
Field is required!
NAME & LOCATION COLLEGE
Field is required!
NAME & LOCATION OTHER
Field is required!

COURSE OF STUDY

COURSE OF STUDY HIGH SCHOOL
Field is required!
COURSE OF STUDY COLLEGE
Field is required!
COURSE OF STUDY OTHER
Field is required!

YEARS COMPLETED

YEARS COMPLETED HIGH SCHOOL:
Field is required!
YEARS COMPLETED COLLEGE
Field is required!
YEARS COMPLETED OTHER
Field is required!

DETAILS

DETAILS HIGH SCHOOL
Field is required!
DETAILS COLLEGE
Field is required!
DETAILS OTHER
Field is required!

OTHER QUALIFICATIONS

Please list any other qualifications that you have and which you believe should be considered.
Field is required!

TO BE READ AND SIGNED BY APPLICANT

I 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 SIGNATURE

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DATE

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APPLICANT (PRINTED)

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