Capela Transport Driver Application

Driver Application

Please answer all questions
Applicant Name

First Name Last Name
Date of Application

Month Day Year
Date
In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, non-job-related disability, or any other protected group status.
To Be Read and Signed by Applicant

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 resend the corrected information to the prospective employer; and
- Have a rebuttal statement attahced to the alleged erroneous information, if the previous employer(s) and I cannot agree on the acuracy of the information.
Signature

Clear
Date

Month Day Year
Date

Applicant to Complete
Name

First Name Middle Name Last Name
Social Security NO
Current Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
How Long?
yr/mo.
Previous Address 1

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How Long?
yr/mo.
Previous Address 2

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How Long?
yr/mo.
Previous Address 3

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How Long?
yr/mo.
Email Address:
example@example.com
Do you have the legal right to work in the United States?
Date of Birth:

Month Day Year
Date
Can you provide proof of age?
Are you currently employed?
If not, how long since leaving last job?
Military Service?

Yes No
Branch
How did you hear about us?
If driver referral, name:
Are you able to perform, with or without reasonable accommodation, the functions of the job for which you have applied as described in the job description?

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 provide the past 10 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 if necessary.)
Employment
Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Contact Person

First Name Last Name
Email
example@example.com
Date

Month Day Year
From
Date

Month Day Year
To
Position
Salary/Wage
Reason for Leaving
Were you subject to the FMCSRs** while employed?

Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes No
Employment
Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Contact Person

First Name Last Name
Email
example@example.com
Date

Month Day Year
From
Date

Month Day Year
To
Position
Salary/Wage
Reason for Leaving
Were you subject to the FMCSRs** while employed?

Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes No

Employment History Cont.
Employement
Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Contact Person

First Name Last Name
Email
example@example.com
Date

Month Day Year
From
Date

Month Day Year
To
Position
Salary/Wage
Reason for Leaving
Were you subject to the FMCSRs** while employed?

Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes No
Employement
Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Contact Person

First Name Last Name
Email
example@example.com
Date

Month Day Year
From
Date

Month Day Year
To
Position
Salary/Wage
Reason for Leaving
Were you subject to the FMCSRs** while employed?

Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes No
*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 qantity requiring placarding.
**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in intersate commerce to transport passengers or property when the vehicle: (1) weighs or has GVWR of 10,001 lbs. 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 3 years
Check this box if NONE
Dates

Month Day Year
Last Accident
Nature of Accident
Head-on, Rear-end, Upset, etc
Fatalities
Injuries
Hazardous Material Spill
Dates

Month Day Year
Next Previous
Nature of Accident
Head-on, Rear-end, Upset, etc
Fatalities
Injuries
Hazardous Material Spill
Dates

Month Day Year
Next Previous
Nature of Accident
Head-on, Rear-end, Upset, etc
Fatalities
Injuries
Hazardous Material Spill
Traffic Convictions

And forfeitures for the past 3 years (other than parking violations).
Check this box if NONE
Location
Date

Month Day Year
Date
Charge
Penalty
Location
Date

Month Day Year
Date
Charge
Penalty
Location
Date

Month Day Year
Date
Charge
Penalty
Driver Experience and Qualifications

Driver Licenses or Permits held in the past 3 years
State
License NO.
Class
Endorsement(s)
Expiration Date

Month Day Year
Date
State
License NO.
Class
Endorsement(s)
Expiration Date

Month Day Year
Date
State
License NO.
Class
Endorsement(s)
Expiration Date

Month Day Year
Date
State
License NO.
Class
Endorsement(s)
Expiration Date

Month Day Year
Date
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

Yes No
Has any license, permit, or privilege ever ben suspended or revoked?

Yes No
If the answer to either question above is YES, please give details:
Date your first CDL was issued?

Month Day Year
Date

Personal References
Name
Address
Phone Number
Please enter a valid phone number.
Relationship
Email
example@example.com
Name
Address
Phone Number
Please enter a valid phone number.
Relationship
Email
example@example.com
Name
Address
Phone Number
Please enter a valid phone number.
Relationship
Email
example@example.com
I authorize you to make such investigations and inquiries of my personal, employment, and/or medical history and other related matters as may be necessary in arriving at a decision. 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 interview(s) may result in termination. I understand, also, that I am required to abide by all rules and regulations of the Company.
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.
Applicant Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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Driver Application

Applicant to Complete

Employment History

Employment

Employment

Employment History Cont.

Employment

Employment

Employment

Employment History Cont.

Employement

Employement

Accident Record

Traffic Convictions

Driver Experience and Qualifications

Driving Experience

Class of Equipment

Education

Personal References