Commercial DriverApplication for Employment

Date

Company Name:

Street Address:

City:

State:

Zip:

Applicant Name

Last

First

Middle

Home Phone

Cell Phone

Current Address

City

State

Zip:

* If at the above residence less than three years, list below all residences for the past three years. Attach a separate sheet if necessary.

Past Address 1

City

State

Zip

Past Address 2

City

State

Zip

Position Applying for

Temporary

Part Time

Full Time

Who Referred You?

Rate of Pay Expected?

Have you ever worked for this company before?

Dates:

From

When

Rate of Pay

Position

Reason for leaving

Names of any relatives employed by this company

Are you currently employed?

If not, how long since leaving last employment?

EDUCATION

Last School Attended

Name

Address

MILITARY EXPERIENCE

Have you ever served in the U.S. Armed Forces?YesNo

If yes, which branch of service:
Describe any military training received relevant to the position for which you are applying.

Are you currently serving in Military Reserves?YesNo

Are you currently serving in National Guard?YesNo

GENERAL

Have you ever been bonded?

Name of bonding company
(Answer only if a job requirement)

Have you ever been convicted of a felony?

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

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

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?YesNo

ALCOHOL 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?YesNo

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?YesNo

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?YesNo

Applicants Signature:

Date:

Witnessed By:

Date:

DRIVER’S LICENSE INFORMATION

Driver	State	License Number	Type	Expiration Date
Licenses held in past 3 years must be shown

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?YesNo

B. Has any license, permit or privilege ever been suspended or revoked?YesNo

C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?YesNo

If you answered “Yes” to A, B, or C, attach a statement giving details.

DRIVING EXPERIENCE

Class of Equipment	Type of Equipment (Van, Tank, Flat, etc.)	Dates From To	Approximate Total Miles
Straight Truck Tractor and Semi-Trailer Twin Other

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:

DRIVER EXPERIENCE AND QUALIFICATION(continued)

ACCIDENT HISTORY

Accident Review for the past 3 years (attach a separate sheet of paper if more space is needed).

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

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 (Attach separate sheet if necessary.) 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

Salary

Reason for Leaving:

Previous Employer:

Supervisor’s Name:

Address:

Phone:

Position Held:

From

Salary

Reason for Leaving:

Previous Employer:

Supervisor’s Name:

Address:

Phone:

Position Held:

From

Salary

Reason for Leaving:

Previous Employer:

Supervisor’s Name:

Address:

Phone:

Position Held:

From

Salary

Reason for Leaving:

Previous Employer:

Supervisor’s Name:

Address:

Phone:

Position Held:

From

Salary

Reason for Leaving:

Previous Employer:

Supervisor’s Name:

Address:

Phone:

Position Held:

From

Salary

Reason for Leaving:

Medical Insurance Card

Driver License

Resume(Optional)

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.

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.

Date

Applicant’s Signature

Apply Now

Commercial DriverApplication for Employment

Applicant Name

Dates:

EDUCATION

Last School Attended

MILITARY EXPERIENCE

GENERAL

DRIVER EXPERIENCE AND QUALIFICATIONS

PHYSICAL HISTORY

ALCOHOL AND CONTROLLED SUBSTANCE STATEMENT

DRIVER’S LICENSE INFORMATION

DRIVING EXPERIENCE

DRIVER EXPERIENCE AND QUALIFICATION(continued)

ACCIDENT HISTORY

MOTOR VEHICLE DRIVING RECORD (MVR)

Traffic Convictions and Forfeitures for the past 3 years other than parking violations.

EMPLOYMENT RECORD

APPLICANT MUST READ AND SIGN

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