GA Transportation Driver Job Application Form

GA Transportation

Eau Claire, WI | 715-379-5832 | gatransportationllc@yahoo.com
Commercial Driver Application

Please fill in all blanks and provide all information requested.
Date

MonthDayYear
Date
Full Name*

First NameMiddle NameLast Name
Email Address*
example@example.com
Phone Number
Date of Birth*

MonthDayYear
Social Security Number*
Must contain 9 digits
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
From Month/Year to Month/Year
If your above address is less than 3 years, continue listing them below to cover the previous three year period.
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
FromMonth/Year toMonth/Year
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
From Month/Year to Month/Year
Are you legally authorized to work in the United States?*

Driver's License Information

Please include all licenses you have held in the last 3 years.
Commercial Driver's License
Year Obtained
License*

StateNumberExpiration Date
License

StateNumberExpiration Date
License

StateNumberExpiration Date
Experience
1) Type of Vehicle Driven*
From blanks to blank
Approximate Mileage Driven*
2) Type of Vehicle Driven
From blanks to blank
Approximate Mileage Driven
3) Type of Vehicle Driven
From blanks to blank
Approximate Mileage Driven
All accidents in the last 3 years.

If none, write NONE.
Accident 1*

Decribe the incident.FatalitiesInjuries
MonthDayYear
Date
Accident 2*

Decribe the incident.FatalitiesInjuries
MonthDayYear
Date
Accident 3*

Decribe the incident.FatalitiesInjuries
MonthDayYear
Date
List all Traffic Violations and/or Convictions in the last 3 years.

If none, write NONE.
Date

MonthDayYear
Date
ViolationStateCommercial Vehicle? (Yes or No)
Date

MonthDayYear
Date
ViolationStateCommercial Vehicle? (Yes or No)
Date

MonthDayYear
Date
ViolationStateCommercial Vehicle? (Yes or No)
Date

MonthDayYear
Date
ViolationStateCommercial Vehicle? (Yes or No)
Have you ever had any driver license denied, suspended, revoked or canceled by any issuing state agency?*
If yes; State of Insurance; Explanation:

Employment History

Employment history in the last 10 years. Account for gaps between employers. If owner/operator, list carriers leased to.
Currently Employed?*
Years of Driving Experience

0 - 2 year3 - 4 yearMore than 4 yrs
Current Employer Details*

Employer Name

Street Address

CityState

Phone Number
Employment Start Date*

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Reason for Leaving*
Previous Employment Information
1) Employer*

Employer Name

Street Address

CityState

Phone Number
Dates of Employment
Employment Start Date*

MonthDayYear
Date
Employment End Date*

MonthDayYear
Date
Were you subject to the Federal Motor Carrier Safety Regulations during this period?*
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?*
Reason for Leaving*
2) Employer*

Employer Name

Street Address

CityState

Phone Number
Dates of Employment
Employment Start Date*

MonthDayYear
Date
Employment End Date*

MonthDayYear
Date
Were you subject to the Federal Motor Carrier Safety Regulations during this period?*
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?*
Reason for Leaving*
3) Employer

Employer Name

Street Address

CityState

Phone Number
Dates of Employment
Employment Start Date

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
Reason for Leaving
4) Employer

Employer Name

Street Address

CityState

Phone Number
Dates of Employment
Employment Start Date

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
Reason for Leaving
5) Employer

Employer Name

Street Address

CityState

Phone Number
Dates of Employment
Employment Start Date

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
Reason for Leaving
6) Employer

Employer Name

Street Address

CityState

Phone Number
Dates of Employment
Employment Start Date

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
Reason for Leaving

For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j.)
As a prospective driver employee, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective employer; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the statement.

Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information, must submit a written request to the prospective employer, which may be done at any time, including when applying or as a late as thirty (30) days after being employed of being notified of denial of employment. The prospective employer has not yet received the requested information from the previous employer(s), then the five (5) business day deadlines will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.
Certification

"I certify 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."
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

GA Transportation

Commercial Driver Application

Driver's License Information

Commercial Driver's License

Experience

All accidents in the last 3 years.

List all Traffic Violations and/or Convictions in the last 3 years.

Employment History

Previous Employment Information

Dates of Employment

Dates of Employment

Dates of Employment

Dates of Employment

Dates of Employment

Dates of Employment

For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j.)

Certification