Commercial Driver Application AFC

Commercial Driver Application

Basic Information
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.
Cell Number
Date of Birth*

MonthDayYear
Date
Social Security

Residency Information
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
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
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)

All Accidents in the Last 3 Years
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)

Employment History (10 Years); Account for Any Gaps in Employment (If Owner/Operator, List Carriers Leased To)
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.
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.
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.
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.
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.
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.
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.
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

Certify and Sign
Signature*

Clear
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