Driver Application

Full Name*

First NameLast Name

Social Security Number*

ex: xxx-xx-xxxx

Current Address*

Street Address

Street Address Line 2

CityState

Zip Code

Have you resided at this address for at least 3 years?*

YesNo

If no, please list all residences for the past 3 years.*

If no, please type N/A.

Date of Birth*

MonthDayYear

Phone Number*

Area CodePhone Number

E-mail*

Have you had any legal name changes?*

YesNo

If yes, please list name(s). *

If no, please type N/A.

Have you ever been convicted of a crime?*

YesNo

Are there any pending charges against you?*

YesNo

If yes, please list city, county, state, month, year, and nature of offense. *

If no, please type N/A.

Have you previously applied at Cordes Inc?*

YesNo

If hired, can you furnish proof of eligibility to work in the United States?*

YesNo

Are you 21 years of age or older?*

YesNo

Position Applying For?

gravel trains, pneumatic tankers, flowboy

Have you been previously employed at Cordes Inc?*

YesNo

Start Date

MonthDayYear

End Date

MonthDayYear

Are you currently employed?*

YesNo

When are you available to start work?*

MonthDayYear

Please list current, or most recent employment first.

Start date*

MonthDayYear

Ending date*

MonthDayYear

Employer Name*

City, State*

Employer phone*

Area CodePhone Number

Position Held*

Reason for leaving*

Is this your current employer?*

YesNo

May we contact this employer?*

YesNo

Was this a driving position?*

YesNo

Were you regulated by FMCSA at this job?*

YesNo

Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance and alcohol testing?*

YesNo

Type of equipment driven*

State(s) driven in*

NEXT EMPLOYER

Start date

MonthDayYear

Ending date

MonthDayYear

Employer Name

City, State

Employer phone

Area CodePhone Number

Position Held

Reason for leaving

Was this a driving position?

YesNo

Were you regulated by FMCSA during this job?

YesNo

Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance and alcohol testing?

YesNo

Type of equipment driven

State(s) driven in

NEXT EMPLOYER

Starting date

MonthDayYear

Ending date

MonthDayYear

Employer Name

City, State

Employer phone

Area CodePhone Number

Position Held

Reason for leaving

Was this a driving position?

YesNo

Were you regulated by FMCSA during this job?

YesNo

Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance and alcohol testing?

YesNo

Type of equipment driven

State(s) driven in

NEXT EMPLOYER

Start Date

MonthDayYear

End Date

MonthDayYear

Employer Name

City and State

Employer Phone

Area CodePhone Number

Position

Reason for leaving

Was this a driving position?

YesNo

Were you regulated by FMCSA during this job?

YesNo

Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance and alcohol testing?

YesNo

Type of equipment driven

State(s) driven in

NEXT EMPLOYER

Start Date

MonthDayYear

End Date

MonthDayYear

Employer Name

City and State

Employer Phone

Area CodePhone Number

Position

Reason for leaving

Was this a driving position?

YesNo

Were you regulated by FMCSA during this job?

YesNo

Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance and alcohol testing?

YesNo

Type of equipment driven

State(s) driven in

NEXT EMPLOYER

Start Date

MonthDayYear

End Date

MonthDayYear

Employer Name

City and State

Employer Phone

Area CodePhone Number

Position

Reason for leaving

Was this a driving position?

YesNo

Were you regulated by FMCSA during this job?

YesNo

Was this job a FMCSA safety sensitive function position subject to DOT regulated controlled substance and alcohol testing?

YesNo

Type of equipment driven

State(s) driven in

Have you held a valid US license for the past 3 years?*

YesNo

Drivers License Number*

License Class*

State of Issue*

License expiration date*

MonthDayYear

Expiration date of DOT physical card

MonthDayYear

CDL Endorsements*

Hazmat expiration date

MonthDayYear

TWIC expiration date

MonthDayYear

Please list any other licenses held in the past 3 years.*

Include state issued, license number, type, endorsements, expiration date

Do you currently hold more than one valid license?*

YesNo

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

YesNo

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

YesNo

Have you ever tested positive or refused a pre-employment drug test for a motor carrier that didn’t hire you in the last 3 years?*

YesNo

Have you ever been disqualified for violations of the Federal Motor Carrier Safety Reg’s (including Drug & Alcohol)?*

YesNo

If you answered yes to any of the above questions, please explain in full detail*

Have you had any moving violations in the last 5 years?*

YesNo

If yes, please include for all violations: date, location, fatalities, injuries, and nature of accident*

Have you had any accidents in the last 5 years?*

YesNo

If yes, please include for all violations: date, location, charge, and penalty*

EDUCATION

Name & City/State of High School

Did you graduate/equivalent?

YesNo

Name & City/State of College

Did you graduate?

YesNo

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty and reason for non-consideration or subsequent dismissal if hired or denial of authorization to drive. It is also agreed and understood that the motor carrier and 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 persons named herein from all liability for any damages on account of his/her furnishing such information.

I authorize the motor carrier to access the FMCSA Pre-Employment Screening Program (PSP) to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years.

I understand that nothing contained in this application or in the granting of any interview or a road test is intended to create an employment contract between this company and myself, for either employment, authorization to drive, or for the providing of any benefits. I agree to furnish such additional information that may be necessary and complete such examinations as may be required to complete my application file including but not limited to a pre-employment negative urine test and successful completion of a human performance evaluation including a Department of Transportation Physical. No promises regarding employment or authorization to drive have been made to me, and no such promises exist unless specifically made by this Company in writing. It is agreed and understood that if qualified, hired, or contract started, I may be on a probationary period during which time I may be disqualified without recourse. I understand employment or authorization to drive with this carrier is on an “at-will” basis that allows me to quit, be fired, or lease agreement revoked at any time with or without notice and with or without cause. 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.

By this document, Motor Carrier Name discloses to you that a consumer report, including an investigative report containing information as to your character, general reputation, personal characteristics, driving record, and mode of living may be obtained as part of a background investigation as part of the Motor Carrier Name’s driver qualification process. Should an investigation consumer report be requested you have the right to demand a complete and accurate disclosure of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act. Please sign below to signify receipt of the foregoing disclosure.

Choose ONE:*

I ACCEPTI DO NOT accept

Name*

First NameLast Name

By signing, I agree I have read the above statements *

Date

Driver Application

General Information

Employment History

Driver Qualification & Experience

Additional Information

Disclosure Statement