Company Driver Application

Name
First Middle Last
Phone
Email
Date of Birth
MM slash DD slash YYYY
Social Security #
Date of Application
MM slash DD slash YYYY
Position Applied For
Date Available for Work
MM slash DD slash YYYY
Do you have legal right to work int he United States?
- YES
- NO

PREVIOUS THREE YEARS OF RESIDENCY
Current Address
Street Address Address Line 2 City State ZIP Code
# of years at address
Mailing Address
Street Address Address Line 2 City State ZIP Code
# of years at address
Previous Address
Street Address Address Line 2 City State ZIP Code
# of years at address
Previous Address
Street Address Address Line 2 City State ZIP Code
# of years at address
Previous Address
Street Address Address Line 2 City State ZIP Code
# of years at address

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). I 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.
State
License #
Type/Class
Endorsements
Expiration Date
MM slash DD slash YYYY
- PREVIOUSLY HELD LICENSE -
State
License #
Type/Class
Endorsements
Expiration Date
MM slash DD slash YYYY
- PREVIOUSLY HELD LICENSE -
State
License #
Type/Class
Endorsements
Expiration Date
MM slash DD slash YYYY

DRIVING EXPERIENCE
- Straight Truck -
Type of Equipment (Van, Tank, Flat, Etc.)
Date From
MM slash DD slash YYYY
Date To
MM slash DD slash YYYY
Approx # of Miles (Total)
MM slash DD slash YYYY
- Tractor & Semi-Trailer -
Type of Equipment (Van, Tank, Flat, Etc.)
Date From
MM slash DD slash YYYY
Date To
MM slash DD slash YYYY
Approx # of Miles (Total)
MM slash DD slash YYYY
- Tractor & 2 Trailers -
Type of Equipment (Van, Tank, Flat, Etc.)
Date From
MM slash DD slash YYYY
Date To
MM slash DD slash YYYY
Approx # of Miles (Total)
MM slash DD slash YYYY
- Tractor & Tanker -
Type of Equipment (Van, Tank, Flat, Etc.)
Date From
MM slash DD slash YYYY
Date To
MM slash DD slash YYYY
Approx # of Miles (Total)
MM slash DD slash YYYY
- Other -
Type of Equipment (Van, Tank, Flat, Etc.)
Date From
MM slash DD slash YYYY
Date To
MM slash DD slash YYYY
Approx # of Miles (Total)
MM slash DD slash YYYY

ACCIDENT RECORD FOR THE PAST 3 YEARS
Check this box if none
- No Accidents
Date (List most recent first)
MM slash DD slash YYYY
Nature of the Accident (head-on, rear-end, upset, etc)
# Fatalities
# Injuries
Chemical Spills
- Yes
- No
---
Date (List most recent first)
MM slash DD slash YYYY
Nature of the Accident (head-on, rear-end, upset, etc)
# Fatalities
# Injuries
Chemical Spills
- Yes
- No
Date (List most recent first)
MM slash DD slash YYYY
Nature of the Accident (head-on, rear-end, upset, etc)
# Fatalities
# Injuries
Chemical Spills
- Yes
- No

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS
Check this box if none
- No Traffic Convictions
Date Convicted
MM slash DD slash YYYY
Violation
State of Conviction
State
Penalty (Forfeited bond, collateral and/or points)
---
Date Convicted
MM slash DD slash YYYY
Violation
State of Conviction
State
Penalty (Forfeited bond, collateral and/or points)
---
Date Convicted
MM slash DD slash YYYY
Violation
State of Conviction
State
Penalty (Forfeited bond, collateral and/or points)
Date Convicted
MM slash DD slash YYYY
---
Date Convicted
MM slash DD slash YYYY
Violation
State of Conviction
State
Penalty (Forfeited bond, collateral and/or points)
---
Date Convicted
MM slash DD slash YYYY
Violation
State of Conviction
State
Penalty (Forfeited bond, collateral and/or points)
---
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
- Yes
- No
Has any license, permit, or privilege ever been suspended or revoked?
- Yes
- No

EDUCATION
High School - Name & Location
Course of Study
Years Completed
Gradudated
- YES
- NO
Details
College - Name & Location
Course of Study
Years Completed
Gradudated
- YES
- NO
Details
Other - Name & Location
Course of Study
Years Completed
Gradudated
- YES
- NO
Details
OTHER QUALIFICATIONS
Please list any other qualifications that you have and which you believe should be considered.

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. 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 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 Name (Printed)
First Last
Date
MM slash DD slash YYYY
Signature

Step 1 of 9

PREVIOUS THREE YEARS OF RESIDENCY

LICENSE INFORMATION

DRIVING EXPERIENCE

ACCIDENT RECORD FOR THE PAST 3 YEARS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS

EMPLOYMENT HISTORY

EDUCATION

OTHER QUALIFICATIONS

TO BE READ AND SIGNED BY APPLICANT

New Truck Driver Position