APPLICANT INFORMATION
Name
Home Phone
Cell Phone
Current Address
If at the above residence less than three years, list below ALL residences for the past three years.
Previous Address 2
Previous Address 3
Position Applying For
Who Referred You
Rate of Pay Expected
If Yes - dates from to
Where?
Rate of Pay
Reason for Leaving
Names of any relatives employed by this company
If not, how long since leaving last employment
EDUCATION
MILITARY EXPERIENCE
If yes, which branch of service
Describe any military training received relevant to the position for which you are applying
GENERAL
Have you ever been bonded?
Name of bonding company
Have you ever been convicted of a felony
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
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.
Applicants Signature
Date
DRIVER'S LICENSE INFORMATION
Driver 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
If you answered 'YES' to A, B, or C, write a statement below giving details
DRIVING EXPERIENCE
Type of Equipment
Dates
Approximate Total Miles
Type of Equipment
Dates
Approximate Total Miles
Type of Equipment
Dates
Approximate Total Miles
Type of Equipment
Dates
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
Nature of Accident
Date
# Fatalaties
# Injuries
# Vehicles Towed
Citation Issued?
Nature of Accident
Date
# Fatalaties
# Injuries
# Vehicles Towed
Citation Issued?
Nature of Accident
Date
# Fatalaties
# 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 97) 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 hte complete mailing address: street number, city, state and zip code.
Current Employer
Supervisor's Name
Address
Position Held
From
To
Salary
Reason for leaving
Previous Employer
Supervisor's Name
Address
Position Held
From
To
Salary
Reason for leaving
Previous Employer
Supervisor's Name
Address
Position Held
From
To
Salary
Reason for leaving
Previous Employer
Supervisor's Name
Address
Position Held
From
To
Salary
Reason for leaving
Previous Employer
Supervisor's Name
Address
Position Held
From
To
Salary
Reason for leaving
Previous Employer
Supervisor's Name
Address
Position Held
From
To
Salary
Reason for leaving
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 herin 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.
Applicant's Signature
Date
Send
