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 that 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.
YOUR NAME   DATE  



























POSITION(S) APPLIED FOR   SOCIAL SECURITY NO.  
LAST   FIRST   MIDDLE  


CURRENT ADDRESS  -  STREET   CITY  
STATE   ZIP CODE   PHONE   HOW LONG (YR./MO)  


PREVIOUS ADDRESS 1  -  STREET   CITY  
STATE   ZIP CODE   HOW LONG (YR./MO)  

PREVIOUS ADDRESS 2  -  STREET   CITY  
STATE   ZIP CODE   HOW LONG (YR./MO)  

PREVIOUS ADDRESS 3  -  STREET   CITY  
STATE   ZIP CODE   HOW LONG (YR./MO)  

DO YOU HAVE THE LEGAL RIGHT TO WORK IN THE UNITED STATES?  
DATE OF BIRTH (REQUIRED FOR COMMERCIAL DRIVERS)   CAN YOU PROVIDE PROOF OF AGE?  
HAVE YOU WORKED FOR THIS COMPANY BEFORE?   WHERE?  
DATES:  FROM   TO   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 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 preceding 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.)

EMPLOYER DATE
NAME   FROM (MO. YR)   TO (MO. YR)  
ADDRESS   POSITION HELD  
CITY   STATE   ZIP   SALARY/WAGE  
CONTACT PERSON   PHONE   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

EMPLOYER DATE
NAME   FROM (MO. YR)   TO (MO. YR)  
ADDRESS   POSITION HELD  
CITY   STATE   ZIP   SALARY/WAGE  
CONTACT PERSON   PHONE   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

EMPLOYER DATE
NAME   FROM (MO. YR)   TO (MO. YR)  
ADDRESS   POSITION HELD  
CITY   STATE   ZIP   SALARY/WAGE  
CONTACT PERSON   PHONE   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

EMPLOYER DATE
NAME   FROM (MO. YR)   TO (MO. YR)  
ADDRESS   POSITION HELD  
CITY   STATE   ZIP   SALARY/WAGE  
CONTACT PERSON   PHONE   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



EMPLOYER DATE
NAME   FROM (MO. YR)   TO (MO. YR)  
ADDRESS   POSITION HELD  
CITY   STATE   ZIP   SALARY/WAGE  
CONTACT PERSON   PHONE   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

EMPLOYER DATE
NAME   FROM (MO. YR)   TO (MO. YR)  
ADDRESS   POSITION HELD  
CITY   STATE   ZIP   SALARY/WAGE  
CONTACT PERSON   PHONE   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 poundsor more, (2) is designed or used to transport more than 8 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, NONE
DATES NATURE OF ACCIDENT
(Head-On, Rear-End, Upset, Etc.)
FATALITIES INJURIES HAZARDOUS MATERIAL SPILL
LAST ACCIDENT  
NEXT PREVIOUS  
NEXT PREVIOUS  














TRAFFIC CONVICTIONS
AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
LOCATION DATE (mm/dd/yyyy) CHARGE PENALTY

EXPERIENCE AND QUALIFICATIONS - DRIVER
DRIVER LICENSES OR PERMITS HELD IN THE PAST 3 YEARS
STATE LICENSE NO. CLASS ENDORSEMENT(S) EXPIRATION DATE
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 DETAILS

DRIVING EXPERIENCE
CLASS OF EQUIPMENT (CHECK YES OR NO) DATES FROM (MM/YYYY) DATES TO (MM/YYYY) APPROX. NO. OF MILES TOTAL
STRAIGHT TRUCK  YES NO
TRACTOR AND SEMI-TRAILER  YES NO
TRACTOR - TWO TRAILERS  YES NO
TRACTOR - THREE TRAILERS  YES NO
MOTORCOACH - SCHOOL BUS
MORE THAN 8 PASSENGERS  YES NO
MOTORCOACH - SCHOOL BUS
MORE THAN 15 PASSENGERS  YES NO
OTHER  
  LIST STATES OPERATED IN FOR LAST FIVE YEARS:



SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM:

EXPERIENCE AND QUALIFICATIONS - (OTHER)
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY:
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION:
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN):

EDUCATION
CHECK HIGHEST GRADE COMPLETED    HIGH SCHOOL    COLLEGE:  

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 ITARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
YOUR NAME:   DATE: