DRIVER'S APPLICATION

DRIVER'S APPLICATION
FOR EMPLOYMENT
Applicant 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 49 CFR 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 cannot agree on the accuracy of the Information.
Signature
APPLICANT INFORMANTION
Position(s) applying for
Please list -,-,-,
Name
Last
First
Middle
Social Security No.
List your addresses of residency for the past 3 years.
Current Address
Street
City
State
Zip Code
Phone
Format: (000) 000-0000.
How Long : yr./mo.
Past Address if applicable
Street
City
State & Zip Code
How Long : yr./mo.
Street
City
State & Zip Code
How Long : yr./mo.
Street
City
State & Zip Code
How Long : yr./mo.
Do you have the legal right to work In the United States?
Date of Birth (Required for Commercial Drivers)

MonthDayYear
Date
Can you provide proof of age?
Have you worked for this company before?
Where?
Dates
From
To
Rate of Pay
Position
Reason for leaving
Are you Employed
If not, how long since leaving last employment?
yr./mo.
Who referred you?
Rate of pay expected
Have you ever been bonded? (Answer only if a Job requirement)
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.
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.
EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or Interstate commerce shall also provide an addi- tional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary
EMPLOYER

Most resent
NAME
ADDRESS
CITY
STATE
Abbreviated ex: ND
ZIP CODE
CONTACT PERSON
PHONE NUMBER
DATE OF EMPLOYMENT
FROM: MO.
FROM: YR.
TO: MO.
TO: YR.
POSITION HELD
SALARY/WAGE
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs+ WHILE EMPLOYED?
CWAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL YESNO TESTING REQUIREMENTS OF 49 CFR PART 40?
DO YOU HAVE ADDITION EMPOYMENT(S)?
- EMPLOYER
- NAME
- ADDRESS
- CITY
- STATE
  Abbreviated ex: ND
- ZIP CODE
- DATE OF EMPLOYMENT
- FROM: MO.
- FROM: YR.
- TO: MO.
- TO: YR.
- CONTACT PERSON
- PHONE NUMBER
- POSITION HELD
- SALARY/WAGE
- REASON FOR LEAVING
- WERE YOU SUBJECT TO THE FMCSRs+ WHILE EMPLOYED?
- CWAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL YESNO TESTING REQUIREMENTS OF 49 CFR PART 40?
- EMPLOYER
- NAME
- ADDRESS
- CITY
- STATE
  Abbreviated ex: ND
- ZIP CODE
- DATE OF EMPLOYMENT
- FROM: MO.
- FROM: YR.
- TO: MO.
- TO: YR.
- CONTACT PERSON
- PHONE NUMBER
- POSITION HELD
- SALARY/WAGE
- REASON FOR LEAVING
- WERE YOU SUBJECT TO THE FMCSRs+ WHILE EMPLOYED?
- WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL YESNO TESTING REQUIREMENTS OF 49 CFR PART 40?
- EMPLOYER
- NAME
- ADDRESS
- CITY
- STATE
  Abbreviated ex: ND
- ZIP CODE
- DATE OF EMPLOYMENT
- FROM: MO.
- FROM: YR.
- TO: MO.
- TO: YR.
- CONTACT PERSON
- PHONE NUMBER
- POSITION HELD
- SALARY/WAGE
- REASON FOR LEAVING
- WERE YOU SUBJECT TO THE FMCSRs+ WHILE EMPLOYED?
- CWAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL YESNO TESTING REQUIREMENTS OF 49 CFR PART 40?
- EMPLOYER
- NAME
- ADDRESS
- CITY
- STATE
  Abbreviated ex: ND
- ZIP CODE
- DATE OF EMPLOYMENT
- FROM: MO.
- FROM: YR.
- TO: MO.
- TO: YR.
- CONTACT PERSON
- PHONE NUMBER
- POSITION HELD
- SALARY/WAGE
- REASON FOR LEAVING
- WERE YOU SUBJECT TO THE FMCSRs+ WHILE EMPLOYED?
- CWAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL YESNO TESTING REQUIREMENTS OF 49 CFR PART 40?
- EMPLOYER
- NAME
- ADDRESS
- CITY
- STATE
  Abbreviated ex: ND
- ZIP CODE
- CONTACT PERSON
- PHONE NUMBER
- DATE OF EMPLOYMENT
- FROM: MO.
- FROM: YR.
- TO: MO.
- TO: YR.
- POSITION HELD
- SALARY/WAGE
- REASON FOR LEAVING
- WERE YOU SUBJECT TO THE FMCSRs+ WHILE EMPLOYED?
- WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL YESNO TESTING REQUIREMENTS OF 49 CFR PART 40?
- *Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding. The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
- ACCIDENT RECORD FOR PAST 3YEARS OR MORE IF NONE,LEAVE NONE
- NATURE OF ACCIDENT LAST
  MOST RESENT
- Date
  
  MonthDayYear
  Date
- FATALITIES
- INJURIES
- HAZARDOUS MATERIAL SPILL
- NATURE OF NEXT PREVIOUS
  MOST RESENT
- Date
  
  MonthDayYear
  Date
- FATALITIES
- INJURIES
- HAZARDOUS MATERIAL SPILL
- NATURE OF NEXT PREVIOUS
  MOST RESENT
- Date
  
  MonthDayYear
  Date
- FATALITIES
- INJURIES
- HAZARDOUS MATERIAL SPILL
- TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, LEAVE NONE
- TRAFFIC VIOLATION(S)
  MOST RESENT
- LOCATION
- Date
  
  MonthDayYear
  Date
- CHARGE
- PENALTY
- LOCATION
- Date
  
  MonthDayYear
  Date
- CHARGE
- PENALTY
- LOCATION
- Date
  
  MonthDayYear
  Date
- CHARGE
- PENALTY
- EXPERIENCE AND QUALIFICATIONS - DRIVER
- DRIVER LICENSES/ PERMITS
  
  PAST 3 YEARS
- STATE
- LICENSE NO.
- TYPE
- Date
  
  MonthDayYear
  Date
- STATE
- LICENSE NO.
- TYPE
- Date
  
  MonthDayYear
  Date
- STATE
- LICENSE NO.
- TYPE
- Date
  
  MonthDayYear
  Date
- A.Have you ever been denied a license, permit or privilege to operate a motor vehicle?
- B.Has any license, permit or privilege ever been suspended or revoked?
- IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS
- DRIVING EXPERIENCE
- STRAIGHT TRUCK
- SELECT TYPE OF EQUIPMENT. (all that apply)
- DATE FROM
  MO/YR
- DATE TO
  MO/YR
- APPROX. NO. OF MILES (TOTAL)
- TRACTOR AND SEMI-TRAILER
- SELECT TYPE OF EQUIPMENT. (all that apply)
- DATE FROM
  MO/YR
- DATE TO
  MO/YR
- APPROX. NO. OF MILES (TOTAL)
- TRACTOR - TWO TRAILERS
- SELECT TYPE OF EQUIPMENT. (all that apply)
- DATE FROM
  MO/YR
- DATE TO
  MO/YR
- APPROX. NO. OF MILES (TOTAL)
- TRACTOR - THREE TRAILERS
- SELECT TYPE OF EQUIPMENT. (all that apply)
- DATE FROM
  MO/YR
- DATE TO
  MO/YR
- APPROX. NO. OF MILES (TOTAL)
- MOTORCOACH - SCHOOL BUS (8+ passengers)
- DATE FROM
  MO/YR
- DATE TO
  MO/YR
- APPROX. NO. OF MILES (TOTAL)
- MOTORCOACH - SCHOOL BUS (15+ passengers)
- DATE FROM
  MO/YR
- DATE TO
  MO/YR
- APPROX. NO. OF MILES (TOTAL)
- OTHER
- DATE FROM
  MO/YR
- DATE TO
  MO/YR
- APPROX. NO. OF MILES (TOTAL)
- LIST STATES OPERATED IN FOR LAST FIVE YEARS
- SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER
- WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
- EXPERIENCE AND QUALIFICATIONS - OTHER
- SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
- LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
- LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)
- EDUCATION
- SELECT HIGHEST GRADE COMPLETED
- HIGHEST COLLEGE YEAR COMPLETED
- LAST SCHOOL ATTENDED
  Name of school
- SCHOOLS LOCATION
  CITY,STATE
- TO BE READ AND SIGNED BY APPLICANT
- 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.
  
  Signature: PAGE 4 15F (Rev. 2/05) 691
- Signature

DRIVER'S APPLICATION

FOR EMPLOYMENT

TO BE READ AND SIGNED BY APPLICANT

APPLICANT INFORMANTION

Name

Dates

EMPLOYMENT HISTORY

EMPLOYER

DATE OF EMPLOYMENT

EMPLOYER

DATE OF EMPLOYMENT

EMPLOYER

DATE OF EMPLOYMENT

EMPLOYER

DATE OF EMPLOYMENT

EMPLOYER

DATE OF EMPLOYMENT

EMPLOYER

DATE OF EMPLOYMENT

ACCIDENT RECORD FOR PAST 3YEARS OR MORE IF NONE,LEAVE NONE

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, LEAVE NONE

EXPERIENCE AND QUALIFICATIONS - DRIVER

DRIVER LICENSES/ PERMITS

DRIVING EXPERIENCE

EXPERIENCE AND QUALIFICATIONS - OTHER

EDUCATION

TO BE READ AND SIGNED BY APPLICANT