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JOB APPLICATION

Name
First Middle Last Suffix
Email
Telephone Number
Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
If at above address for less than 3 years, list below all residences for the last 3 years.
Next of kin
Name Relationship Valid phone number
Experience & Qualifications
Date of Birth
MM
DD
YYYY
Social Security #
Drivers License #
State
Expires
List all drivers licenses held in the last 3 years
License # Issuing State Expiration
Have you beed denied a license, permit or privilege to operate a motor vehicle. If so, explain circumstances.
Have any licenses, permits or privileges ever been suspended or revoked?. If so, explain circumstances.
General
Have you ever been convicted of a felony
- Yes
- No
Please explain. Conviction of a crim eis not an automatic bar to certification, all circumstances will be considered.
How did you hear about our Company? (If from another driver please list their name.)
Have you ever failed or refused a DOT drug screen
- Yes
- No
Education
Select highest grade completed
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- College 1
- College 2
- College 3
- College 4
Last school attended
Name & City/state
Accidents
List all commercial vehicle accidents in which you have been invo;ved in during the last 3 years.
Date Nature of accident Fatalities Injuries
Traffic convictions and forfeitures
List all traffic convictions and forfeitures in the last 3 years
Location Date Charge Penalty
Driving Experience
Straight Truck
Type of Equipment Date Approx. Miles
Tractor and Semi-Trailer
Type of Equipment Date Approx. Miles
Tractor-Two Trailers
Type of Equipment Date Approx. Miles
Other
Type of Equipment Date Approx. Miles
How many states have you driven in the past 5 years
List any special courses or training that will help you as a driver
List any safe driving awards you may have received
Employment History
Driver applicants must list ALL past and present employers for the past 3 years, This means EVERY job you have had, whether it was a driving or non-driving job. If you were self-employed, unemployed, or not working, you MUST fill in those dates. YOU MUST PROVIDE DATES FOR THE PAST 36 MONTHS. This is a Department of Transportation requirement. Applicants for driving positions must also provide AN ADDITIONAL 7 years or information an ALL DRIVING POSITIONS you have had. (List ALL jobs in the past 36 months - ALL DRIVING POSITIONS in the past 10 years.) Information MUST be COMPLETE. (LIST EMPLOYERS IN REVERSE ORDER - STARTING WITH THE MOST RECENT)

Current or Last Employer

Company Name	Address	City	State	Zip	Phone #	Position	Reason for leaving	Was this job designated as a safety sensitive function that required DOT drug/alcohol testing? (Yes or No)	Is this company regulated by DOT?	Start date (MM/YY)	End date(MM/YY)