Driver Employment Application

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.

I understand that in order to be considered for employment as a commercial motor vehicle driver, a full query of the FMCSA Drug and Alcohol Clearinghouse (Clearinghouse) will be requested and my consent will be required electronically through the Clearinghouse. Please visit the Clearinghouse website at https://clearinghouse.fmcsa.dot.gov/register for additional information & for FMCSA Driver Registration.

I hereby provide consent to the Company to conduct limited queries of the Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. These limited queries can be made at any point throughout the duration of my employment with the Company.

I understand that if the limited query conducted by the Company indicates that drug or alcohol violation information about be exist in the Clearinghouse, FMCSA will not disclose that information to the Company without first obtaining additional specific consent from me.

I further understand that if I refuse to provide consent for the Company to conduct a limited or full query of the Clearinghouse, the Company must prohibit me performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations.

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 Signature*

Date*

**We are an Equal Opportunity Employer**

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.

PERSONAL INFORMATION

Name*

First Middle Last

Present Address*

Street Address Address Line 2 City State ZIP Code

Number of years at this address*

Past 3 Year Residency: Previous Address

Street Address Address Line 2 City State

Number of years at this address

Past 3 Year Residency: Previous Address

Street Address Address Line 2 City State

Number of years at this address

Home Phone

Cell Phone*

Email Address

Email*

Age*

Date of Birth*

Social Security Number*

Do you have a legal right to be employed in the United States?*

Are you over the age of 18?*

EMPLOYMENT HISTORY

All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record). You are required to list the complete mailing address: street number and name, city, state and zip code.

CURRENT OR LAST EMPLOYER: Name of Organization*

Job Title & Dates of Employment*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Length of Service & Reasons for Leaving*

Were you subject to the Federal Motor Carrier Safety Regulations** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS: Include dates (month/year) and reason.

SECOND LAST EMPLOYER: Name of Organization*

Job Title & Dates of Employment*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Length of Service & Reasons for Leaving*

Were you subject to the Federal Motor Carrier Safety Regulations** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS: Include dates (month/year) and reason.

THIRD LAST EMPLOYER: Name of Organization

Job Title & Dates of Employment

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Length of Service & Reasons for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS: Include dates (month/year) and reason.

*Any gaps in employment and/or unemployment must be explained.

**The Federal Motor Carrier Safety Regulations 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 GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

References

Please provide three (3) references.

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Experience and Qualification

Check Here, If no driving experience within the last 3 years

Straight Truck Type of Equipment

Van
Reefer
Tank
Flat

Dates: FROM

Dates: TO

Tractor & Semi-Trailer Type of Equipment

Van
Reefer
Tank
Flat

Dates: FROM

Dates: TO

Tractor – Two Trailers Type of Equipment

Van
Reefer
Tank
Flat

Dates: FROM

Dates: TO

Tractor – Three Trailers Type of Equipment

Van
Reefer
Tank
Flat

Dates: FROM

Dates: TO

Other Type of Equipment

Van
Reefer
Tank
Flat

Dates: FROM

Dates: TO

Motorcoach (greater than 8 passengers) – School Bus

Dates: FROM

Dates: TO

Motorcoach (greater than 15 passengers) – School Bus

Dates: FROM

Dates: TO

Accident History (3 years)

Check Here, If no accidents within the last 3 years

Date

Nature of Accident

(head-on, rear-end, upset, etc.)

Number of fatalities

Number of Injuries

Hazardous Materials Spill?

Date

Nature of Accident

(head-on, rear-end, upset, etc.)

Number of fatalities

Number of Injuries

Hazardous Materials Spill?

Date

Nature of Accident

(head-on, rear-end, upset, etc.)

Number of fatalities

Number of Injuries

Hazardous Materials Spill?

Traffic Convictions and Forfeitures (3 years)

Check Here, If no traffic convictions and/or forfeitures in the last 3 years

Date Convicted

Violation

(Other than violations involving parking only)

State of Violation

Penalty

(Forfeited bond, collateral and/or points)

Date Convicted

Violation

(Other than violations involving parking only)

State of Violation

Penalty

(Forfeited bond, collateral and/or points)

License Information

Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.

State*

License Number*

Expiration Date*

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

Give Details

Has any license, permit, or privilege ever been suspended or revoked?*

Give Details

What Class of CDL do you hold?*

Can you drive a Straight Truck?*

YES
NO

Applicant Certification

I certify that I have read and understood all of this employment application. It is agreed and understood that the employer of his agents may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons named herein from all liability for any damages on account of 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 which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the results of physical examination and drug test.

I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason.

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 my result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of the employer.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Applicant Signature*

Date*

Equal Employment Opportunity

Equal Employment Opportunity Data Reporting Form

The Federal Highway Administration(FHWA) requires the following information to be collected for statistical reporting of applicants as a part of the equal Opportunity and Affirmative Action Program requirements (FHWA-1273). This information is not used in the employment process nor released in a manner that identifies the individual. This form will be removed prior to being forwarded to the hiring authority

Today's Date*

Name*

First Middle Initial Last

Position for which you are applying*

Gender*

Date of birth*

Race(Please check ap propriate box)*

White, not of Hispanic Origin
Black or African American, not of Hispanic Origin
Hispanic or Latino
Asian, not Hispanic or Latino
Native Hawaiian or Other Pacific Islander, not Hispanic or Latino
American Indian or Alaskan Native
Two or more races, not Hispanic or Latino

CAPTCHA

Unique ID

PERSONAL INFORMATION

EMPLOYMENT HISTORY

References

Experience and Qualification

Accident History (3 years)

Traffic Convictions and Forfeitures (3 years)

License Information

Applicant Certification

Equal Employment Opportunity

Equal Employment Opportunity Data Reporting Form

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