Date of Application: (mm/dd/yyyy)
Position Applied For:
First Name:
Middle Name:
Last Name:
Social Security Number: (xxx-xx-xxxx)
List your addresses of residence for the past 3 years with your current address.
Current Address: (include city, state, and zip on this line)
How Long?:
Home Phone: xxx-xxx-xxxx
Mobile Phone:
Previous Address: include city, state, and zip on this line
How Long?:
Do you have the legal right to work in the United States?:
Yes
No
Date of Birth: (required for commercial drivers) (mm/dd/yyyy)
Can you provide proof af age?:
Yes
No
Have you worked for the company before?:
Yes
No
If yes, where?:
Date From: (mm/yyyy)
Date To: (mm/yyyy)
Rate of Pay:
Position held:
Reason for leaving:
Are you currently employed?:
Yes
No
If not, how long since leaving last position?:
Who referred you?:
Rate of Pay Expected:
Is there any reason you might be unable to perform the functions of the job for which you have applied and is described in the attached job description?:
Yes
No
If yes, please explain:
All driver applicants to drive in INTRASTATE OR INTERSTATE COMMERCE must provide the following information on all
employers during the preceding 10 years. List complete mailing address, street address, city, state, zip code,
contact and phone numbers for each. No application will be processed without this information. Applicants to drive
a COMMERCIAL MOTOR VEHICLE* must provide this information
Most Recent Employer
Employer name:
Address:
City:
State:
ZIP:
Contact person:
Contact phone: (xxx-xxx-xxxx)
Date from: (mm/yyyy)
Date to: (mm/yyyy)
Position held:
Salary/Wage:
Reason for leaving:
Next Most Recent Employer
Employer name:
Address:
City:
State:
ZIP:
Contact person:
Contact phone: (xxx-xxx-xxxx)
Date from: (mm/yyyy)
Date to: (mm/yyyy)
Position held:
Salary/Wage:
Reason for leaving:
Next Most Recent Employer
Employer name:
Address:
City:
State:
ZIP:
Contact person:
Contact phone: (xxx-xxx-xxxx)
Date from: (mm/yyyy)
Date to: (mm/yyyy)
Position held:
Salary/Wage:
Reason for leaving:
Next Most Recent Employer
Employer name:
Address:
City:
State:
ZIP:
Contact person:
Contact phone: (xxx-xxx-xxxx)
Date from: (mm/yyyy)
Date to: (mm/yyyy)
Position held:
Salary/Wage:
Reason for leaving:
Next Most Recent Employer
Employer name:
Address:
City:
State:
ZIP:
Contact person:
Contact phone: (xxx-xxx-xxxx)
Date from: (mm/yyyy)
Date to: (mm/yyyy)
Position held:
Salary/Wage:
Reason for leaving:
Accident record - past 3 years or more (if none then type "none" in the first box)
Last accident date: (mm/yyyy)
Nature of accident: (head-on, rear-end, upset, etc.)
Fatalities:
Yes
No
Injuries:
Yes
No
Last prevous accident date: (mm/yyyy)
Nature of accident: (head-on, rear-end, upset, etc.)
Fatalities:
Yes
No
Injuries:
Yes
No
Last prevous accident date: (mm/yyyy)
Nature of accident: (head-on, rear-end, upset, etc.)
Fatalities:
Yes
No
Injuries:
Yes
No
Last prevous accident date: (mm/yyyy)
Nature of accident: (head-on, rear-end, upset, etc.)
Fatalities:
Yes
No
Injuries:
Yes
No
Traffic convictions & forfeitures for past 3 years (other than parking violations). If none, then type "none" in the first space.
Date: (mm/yyyy)
Location City/State:
Charge:
Penalty:
Date: (mm/yyyy)
Location City/State:
Charge:
Penalty:
Date: (mm/yyyy)
Location City/State:
Charge:
Penalty:
Date: (mm/yyyy)
Location City/State:
Charge:
Penalty:
Education
Select highest grade completed
8
9
10
11
12
13
14
15
16
Last school attended:
City/State:
Experience and Qualifications: Driver
Driver's license number:
Driver's license: (state)
Driver's license type:
Driver's license expiration date:
Driver's license number:
Driver's license: (state)
Driver's license type:
Driver's license expiration date:
Driver's license number:
Driver's license: (state)
Driver's license type:
Driver's license expiration date:
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Yes No
Has any license, permit, or privilege ever been suspended or revoked?
Yes
No
If the answer to either of the two previous questions is "Yes", please give statement of details.
Driving Experience: (if none, type "none" in the first space).
Class of Equipment: Straight Truck
Type of equipment: (van, tank, flat, etc.)
Date From: (mm/yyyy)
Date To: (mm/yyyy)
Miles:
Class of Equipment: Tractor/Semi Trailer
Type of equipment: (van, tank, flat, etc.)
Date From: (mm/yyyy)
Date To: (mm/yyyy)
Miles:
Class of Equipment:Tractor-Two Trailers
Type of equipment: (van, tank, flat, etc.)
Date From: (mm/yyyy)
Date To: (mm/yyyy)
Miles:
Class of Equipment: Motorcoach/School Bus
Type of equipment: (van, tank, flat, etc.)
Date From: (mm/yyyy)
Date To: (mm/yyyy)
Miles:
List states operated in for last five years
Show special courses or training that will help you as a driver
Which, if any, safe driving awards do you hold and from whom
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 equipmet or technical materials you can work with (other than those already shown)
To be read and signed by the applicant
By my electronic signature below, I cerify that this application was completed by me, and that all entries
on it and information in it are true, correct, and complete to the best of my knowledge and belief.(Generally, inquiries regarding medical history
will be made only if and after a conditiional offer of emplayment or contract has been extended.)
Applicant's signature
Date: (mm/dd/yyyy)
