DRIVER’S APPLICATION FOR EMPLOYMENT

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DRIVER’S APPLICATION FOR EMPLOYMENT
Name*

First NameLast Name
Date of Application*

MonthDayYear
Date
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 inter-view(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 employer(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 can not agree on the accuracy of the information.
Signature*

Clear
Date*

MonthDayYear
Date

Personal Information
APPLICANT TO COMPLETE

Personal Information
Position(s) Applied for*
Last*
First*
Middle*
Social Security No.*
xxx-xx-xxxx
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Type a question
How long have you lived here*
YR/MO
Phone Number*
Have you lived in any other address in the last 3 years?*

YESNO
List your addresses of residency for the past 3 years.
Previous Address 1

Street Address

Street Address Line 2

CityState

Zip Code
How long have you lived here
YR/MO
Previous Address 2

Street Address

Street Address Line 2

CityState

Zip Code
How long have you lived here
YR/MO
Previous Address 3

Street Address

Street Address Line 2

CityState

Zip Code
How long have you lived here
YR/MO
Do you have the legal right to work in the United States?*
Date of Birth*

MonthDayYear
Date
Can you provide proof of age?*
Have you worked for this company before?*
Where?
From

MonthDayYear
Date
To

MonthDayYear
Date
Rate of Pay
Position
Reason for leaving
Are you now employed?*
If not, how long since leaving last employment?
Who referred you?
Have you ever been bonded?
Name of bonding company
Have you ever been convicted of a felony?*
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered. If your state does not allow for this question please select N/A.
Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]?*
If yes, explain if you wish.

Driving Records
Accident Records
Have you had a accident in the last 3 years?*
Accident 1
Date of accident

MonthDayYear
Date
Nature of Accident
(HEAD-ON, REAR-END, UPSET, ETC.)
Fatalities
Injuries
Hazardous Material Spill
Any other accidents to report in the last 3 years?
Accident 2
Date of accident

MonthDayYear
Date
Nature of Accident
(HEAD-ON, REAR-END, UPSET, ETC.)
Fatalities
Injuries
Hazardous Material Spill
Any other accidents to report in the last 3 years?
Accident 3
Date of accident

MonthDayYear
Date
Nature of Accident
(HEAD-ON, REAR-END, UPSET, ETC.)
Fatalities
Injuries
Hazardous Material Spill
If you have more to report in the last 3 years, Please contact Recruiting.
TRAFFIC CONVICTION

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
Have you had any Traffic Convictions in the last 3 years?*
Traffic Conviction 1
Location
Town and State
Date

MonthDayYear
Date of citation
Charge
Penalty
Any others Traffic Convictions to report?
Traffic Conviction 2
Location
Town and State
Date

MonthDayYear
Date of citation
Charge
Penalty
Any others Traffic Convictions to report?
Traffic Conviction 3
Location
Town and State
Date

MonthDayYear
Date of citation
Charge
Penalty
If you have more to report in the last 3 years, Please contact Recruiting.