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Commercial Driver Application
Company Information
Date:
Company Name
Street Address
City
State
Zip
Applicant Information
Last Name
First Name
M.I.
Current Street Address
Apt/Unit #
City
State
Zip
*If the above residence less than three years, list below all residences for the past three years below.
Previous Street Address
Apt/Unit #
City
State
Zip
Previous Street Address
Apt/Unit #
City
State
Zip
Home Phone
Cell Phone
Position Applying For
Term of Employment (REQUIRED)
Select
Temporary
Part-Time
Full-Time
Who Referred You?
Rate of Pay Expected?
Have you ever worked for this company? (REQUIRED)
Yes
No
From (month/year)
To (month/year)
Where?
Rate of Pay
Position
Reason for Leaving
Names of any relatives employed by this company
Are you currently employed?
Yes
No
If not, how long since leaving last employment?
Education
Select highest grade completed (REQUIRED)
Select
1
2
3
4
5
6
7
8
9
10
11
12
College
Select
1
2
3
4
Last School Attended
Address
Military Service
Have you ever served in the U.S. Armed Forces?
Yes
No
If yes, which brand of service:
Describe any military training received relevant to the position for which you are applying
Are you currently serving in Military Reserves?
Yes
No
Are you currently serving in National Guard?
Yes
No
General
Have you ever been bonded?
(Answer only if a job requirement)
Yes
No
Name of bonding company
Have you ever been convicted of a felony? (REQURIED)
Yes
No
If yes, please explain below.
Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.
Driver Experience and Qualifications
The Federal Motor Carrier Safety Regulations (49CFR391.21 (b) (2) requires that driver applicants state their date of birth and SS #.
Date of Birth (xx/xx/xxxx)
Social Security Number
Physical History
The Federal Motor Carrier Safety Regulations (49CFR391 Subpart E) requires that all driver applicants pass certain physical tests before they are hired to drive a motor vehicle.
Date of last Department of Transportation prescribed examination
Can you provide a copy? (REQUIRED)
Yes
No
Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, leg, hand or arm? (REQUIRED)
Yes
No
Alochol and Controlled Substance Statement
The Federal Motor Carrier Safety Regulations 49CFR40.25(j) requires all persons with applying for a driving position requiring a commercial drivers license to answer the following questions:
1) Within the last two years, have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work? (REQUIRED)
Yes
No
2) Within the last two years, have you ever tested positive, or refused to test, on any type of drug or alcohol test administered by an employer for which you preformed safety-sensitive transportation work? (REQUIRED)
Yes
No
3) If you answered yes to either 1 or 2 above, can you provide and/or obtain proof that you have successfully completed the DOT return-to-duty requirements? (REQUIRED)
Yes
No
Driver's License Information
Driver's Licenses held in the past 3 years must be shown.
State
License Number
Type
Expiration Date
State
License Number
Type
Expiration Date
State
License Number
Type
Expiration Date
State
License Number
Type
Expiration Date
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? (REQUIRED)
Yes
No
B. Has any license, permit or privilege ever been suspended or revoked? (REQUIRED)
Yes
No
C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? (REQUIRED)
Yes
No
If you answered "Yes" to A, B, or C, please provide a statement giving details.
Driving Experience
Straight Truck
Type of Equipment (Van, Tank, Flat, etc.)
Dates (From - To)
Approximate Total Miles
Tractor and Semi-Trailer
Type of Equipment (Van, Tank, Flat, etc.)
Dates (From - To)
Approximate Total Miles
Twin
Type of Equipment (Van, Tank, Flat, etc.)
Dates (From - To)
Approximate Total Miles
Other
Type of Equipment (Van, Tank, Flat, etc.)
Dates (From - To)
Approximate Total Miles
List states operated in during the last five years:
List special courses or training that will help you as a driver:
List safe driving awards held and who awards were presented by:
Accident History
Accident review for the past 3 years.
Date
Nature of Accident (Head-On, Rear-End, Upset, Etc.)
# Fatalities
# Injuries
# Vehicles Towed
Citation Issued?
Date
Nature of Accident (Head-On, Rear-End, Upset, Etc.)
# Fatalities
# Injuries
# Vehicles Towed
Citation Issued?
Date
Nature of Accident (Head-On, Rear-End, Upset, Etc.)
# Fatalities
# Injuries
# Vehicles Towed
Citation Issued?
Motor Vehicle Driving Record (MVR)
Traffic Convictions and Forfeitures for the past 3 years other than parking violations.
Date
Location
Charge
Penalty
Date
Location
Charge
Penalty
Date
Location
Charge
Penalty
Employment Record
The Federal Motor Carrier Safety Regulations (49CFR391.21) 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 must be explained.
Start with the last or current position, including any military experience, and work back. You are required to list the complete mailing address: street number, city, state and zip code.
Current Employer
Supervisor's Name
Address
Phone
Position Held
From (Mo/Yr)
To (Mo/Yr)
Salary
Previous Employer
Supervisor's Name
Address
Phone
Position Held
From (Mo/Yr)
To (Mo/Yr)
Salary
Previous Employer
Supervisor's Name
Address
Phone
Position Held
From (Mo/Yr)
To (Mo/Yr)
Salary
Previous Employer
Supervisor's Name
Address
Phone
Position Held
From (Mo/Yr)
To (Mo/Yr)
Salary
Previous Employer
Supervisor's Name
Address
Phone
Position Held
From (Mo/Yr)
To (Mo/Yr)
Salary
Applicant Must Read and Sign
I certify that I have read and understand all of this employment application. It is agreed and understood that the employer or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and other persons named herein from all liability for any damages on account of his furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks that are pertinent to the job.
It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, personal reputation, personal characteristics and mode of living. You are also being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.
I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal. If hired, I agree to abide by all the rules and policies of the employer.
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.
I acknowledge that submission of this form will act as my electronic signature
Date:
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