Commercial Driver Application AFC

Commercial Driver Application
- Basic Information
- Application Date
  
  MonthDayYear
  Date
- Name*
  
  First nameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Cell Number
  Format: (000) 000-0000.
- Date of Birth*
  
  MonthDayYear
  Date
- Social Security
- Residency Information
- Have you been at the address above for the last 3 years? If no, please fill in the fields below to cover any gaps in the last 3 years. *
- Address 1
- Move in Date, You started living at this address
  
  MonthDayYear
  Date
- Move out Date, you started living at this address
  
  MonthDayYear
  Date
- Address 2
- Move in Date, you started living at this address
  
  MonthDayYear
  Date
- Move out Date, you started living at this address
  
  MonthDayYear
  Date
- Address 3
- Move in Date, you started living at this address
  
  MonthDayYear
  Date
- Move out Date, you started living at this address
  
  MonthDayYear
  Date
- Additional Addresses
  EX: Address4 (Street, City, State, Zip Code), Move In Date - Move Out Date
- All Driver's License(s) Information Held in the Last 3 Years
- License 1 License Number
- License 1 State
- License 1 Expiration Date
  
  MonthDayYear
  Date
- License 2 License Number
- License 2 State
- License 2 Expiration Date
  
  MonthDayYear
  Date
- License 3 License Number
- License 3 State
- License 3 Expiration Date
  
  MonthDayYear
  Date
- Driver Experience
- Type of Vehicle Driven (Vehicle 1)
- Starting Date (Vehicle 1)
  
  MonthDayYear
  Date
- Ending Date (Vehicle 1)
  
  MonthDayYear
  Date
- Approximate Miles Driven (Vehicle 1)
- Type of Vehicle Driven (Vehicle 2)
- Starting Date (Vehicle 2)
  
  MonthDayYear
  Date
- Ending Date (Vehicle 2)
  
  MonthDayYear
  Date
- Approximate Miles Driven (Vehicle 2)
- Type of Vehicle Driven (Vehicle 3)
- Starting Date (vehicle 3)
  
  MonthDayYear
  Date
- Ending Date (Vehicle 3)
  
  MonthDayYear
  Date
- Approximate Miles Driven (Vehicle 3)
- Have you been in any accidents in the last 3 years? If yes, please describe any accidents in the fields below.*
- Date (Accident 1)
  
  MonthDayYear
  Date
- Description (Accident 1)
- Fatalities (Accident 1)
- Injuries (Accident 1)
- Date (Accident 2)
  
  MonthDayYear
  Date
- Description (Accident 2)
- Fatalities (Accident 2)
- Injuries (Accident 2)
- Date (Accident 3)
  
  MonthDayYear
  Date
- Description (Accident 3)
- Fatalities (Accident 3)
- Injuries (Accident 3)
- Have you been cited for any traffic violations in the last 3 years?* If yes, please describe any violations in the fields below.*
- Violation Date (Violation 1)
  
  MonthDayYear
  Date
- Violation (Violation 1)
  What was the violation?
- State (Violation 1)
  Which state did the violation occur in?
- In a Commercial Vehicle? (Violation 1)
  
  YesNo
- Violation Date (Violation 2)
  
  MonthDayYear
  Date
- Violation (Violation 2)
- State (Violation 2)
- In a Commercial Vehicle? (Violation 2)
  
  YesNo
- Violation Date (Violation 3)
  
  MonthDayYear
  Date
- Violation (Violation 3)
- State (Violation 3)
- In a Commercial Vehicle? (Violation 3)
  
  YesNo
- Violation Date (Violation 4)
  
  MonthDayYear
  Date
- Violation (Violation 4)
- State (Violation 4)
- In a Commercial Vehicle? (Violation 4)
  
  YesNo
- Violation Date (Violation 5)
  
  MonthDayYear
  Date
- Violation (Violation 5)
- State (Violation 5)
- In a Commercial Vehicle? (Violation 5)
  
  YesNo
- Violation Date (Violation 6)
  
  MonthDayYear
  Date
- Violation (Violation 6)
- State (Violation 6)
- In a Commercial Vehicle? (Violation 6)
  
  YesNo
- Violation Date (Violation 7)
  
  MonthDayYear
  Date
- Violation (Violation 7)
- State (Violation 7)
- In a Commercial Vehicle? (Violation 7)
  
  YesNo
- Have you ever had any driver's license suspended, denied, revoked, or canceled by any issuing state agency?**
- If yes, please describe the reason.
- Reason for License Revocation, Cancellation, Denial, or Suspension
- Employment History 10 Years; Account for Any Gaps in Employment
- Employer
- Starting Date
  
  MonthDayYear
  Date
- Ending Date
  
  MonthDayYear
  Date
- Company Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip CodeCountry
- Supervisor Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Were you subject to the Federal Motor Carrier Safety Regulations during this period?
  
  YesNo
- Were you subject to 49 part 40 controlled substance and alcohol testing during this period?
  
  YesNo
- Reason For Leaving
- Employer
- Starting Date
  
  MonthDayYear
  Date
- Ending Date
  
  MonthDayYear
  Date
- Company Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Supervisor Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Were you subject to the Federal Motor Carrier Safety Regulations during this period?
  
  YesNo
- Were you subject to 49 part 40 controlled substance and alcohol testing during this period?
  
  YesNo
- Reason For Leaving
- Employer
- Starting Date
  
  MonthDayYear
  Date
- Ending Date
  
  MonthDayYear
  Date
- Company Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Supervisor Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Were you subject to the Federal Motor Carrier Safety Regulations during this period?
  
  YesNo
- Were you subject to 49 part 40 controlled substance and alcohol testing during this period?
  
  YesNo
- Reason For Leaving
- Employer
- Starting Date
  
  MonthDayYear
  Date
- Ending Date
  
  MonthDayYear
  Date
- Company Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Supervisor Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Were you subject to the Federal Motor Carrier Safety Regulations during this period?
  
  YesNo
- Were you subject to 49 part 40 controlled substance and alcohol testing during this period?
  
  YesNo
- Reason For Leaving
- Employer
- Starting Date
  
  MonthDayYear
  Date
- Ending Date
  
  MonthDayYear
  Date
- Company Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Supervisor Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Were you subject to the Federal Motor Carrier Safety Regulations during this period?
  
  YesNo
- Were you subject to 49 part 40 controlled substance and alcohol testing during this period?
  
  YesNo
- Reason For Leaving
- Employer
- Starting Date
  
  MonthDayYear
  Date
- Ending Date
  
  MonthDayYear
  Date
- Company Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Supervisor Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Were you subject to the Federal Motor Carrier Safety Regulations during this period?
  
  YesNo
- Were you subject to 49 part 40 controlled substance and alcohol testing during this period?
  
  YesNo
- Reason For Leaving
- Employer
- Starting Date
  
  MonthDayYear
  Date
- Ending Date
  
  MonthDayYear
  Date
- Company Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Supervisor Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Were you subject to the Federal Motor Carrier Safety Regulations during this period?
  
  YesNo
- Were you subject to 49 part 40 controlled substance and alcohol testing during this period?
  
  YesNo
- Reason For Leaving
- Signature*
- Signature Date*
  
  MonthDayYear
  Date
- Should be Empty:

Commercial Driver Application

Basic Information

Residency Information

All Driver's License(s) Information Held in the Last 3 Years

Driver Experience

Employment History 10 Years; Account for Any Gaps in Employment