Driver's Application for Employment

Applicant Name:
Company:
City:	State:	Zip:

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 employers(s) will be contacted, for the purpose of investigating my safety performance history as required by 49CFR 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.

Signature:

APPLICANT TO COMPLETE

Position(s) Applied for:

Name:

Social Security Number:

List your addresses of residency for the past 3 years.

Current Address:

Phone: How Long?

Previous Addresses:

How Long?

Do you have the legal right to work in the United States?

Date of Birth

Can you provide proof of age?

Have you worked for this company before?

Where?

Dates: From

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?

Name of bonding company

Have you ever been convicted of a felony?

If yes, please explain fully below. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.

Is there any reason you might be unable to perform the functions of the job for which you have applied?

If yes, explain if you wish.

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive 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	To
Address:
City:
Contact Person: Phone Number:
Where 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	To
Address:
City:
Contact Person: Phone Number:
Where 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	To
Address:
City:
Contact Person: Phone Number:
Where 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	To
Address:
City:
Contact Person: Phone Number:
Where 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	To
Address:
City:
Contact Person: Phone Number:
Where 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	To
Address:
City:
Contact Person: Phone Number:
Where 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 ona highway in interstate commerce to transport passengers or property when the vehilce: (1) weighs o has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is any size and is used to transport hazardous materials in a quantity requiring placarding.

ACCIDENT RECORD for past 3 years or more if none, write NONE

DATES	NATURE OF ACCIDENT (head-on, rear-end, upset, etc.)	FATALITIES	INJURIES	HAZARDOUS MATERIAL SPILL

TRAFFIC CONVICTIONS and forfeitures for the past 3 years (other than parking violations) if none, write NONE

LOCATION	DATE	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 licsnse, 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

CLASS OF EQUIPMENT	TYPE OF EQUIPMENT	DATES		APPROX. NO. OF MILES (total)
Straight Truck Yes No	Van Tank Flat Dump Refer
Tractor and Semi-Trailer Yes No	Van Tank Flat Dump Refer
Tractor - Two Trailers Yes No	Van Tank Flat Dump Refer
Tractor - Three Trailers Yes No	Van Tank Flat Dump Refer
Motorcoach - School Bus Yes No More than 8 passengers	----------
Motorcoach - School Bus Yes No More than 15 passengers	----------
Other:

List states operated in for the 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

Highest grade completed: 1 2 3 4 5 6 7 8 High School: 1 2 3 4 College: 1 2 3 4

Last school attended

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 it are true and complete to the best of my knowledge.

Signature:

Date: