Driver's Application for Employment

Truck Driver Application for Employment
Location for which you are applying:*
Date of Application

YearMonthDay
Date
Name*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*

YearMonthDay
Date
Social Security Number*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List the approximate dates for this residence.*
Have you lived anywhere else in the last 3 years?
Choose either "Yes" or "No."
- Previous Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- List the approximate dates for this residence.
- Have you lived anywhere else in the last 3 years?
  Choose either "Yes" or "No."
- Second Previous Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- List the approximate dates for this residence.
- Have you lived anywhere else in the last 3 years?
  Choose either "Yes" or "No."
- Third Previous Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- List the approximate dates for this residence.
- Have you lived anywhere else in the last 3 years?
  Choose either "Yes" or "No."
- Have you ever worked for ProVia before?
  Choose either "Yes" or "No."
- At which ProVia location did you work?
- List the date for working at ProVia.
  From - To
- Position?
- Rate of Pay?
- What was the reason for leaving ProVia?
- How long since your last employment?
- Did someone refer you to ProVia?
  Choose "Yes" or "No"
- Name of the person who referred you:
  Type the name of the person who referred you to ProVia here.

Driving Record
- Have you been involved in any accidents within the last 3 years?*
  Choose either "Yes" or "No."
- When was your last accident?
  
  MonthDayYear
  Date
- Describe the nature of your last accident.
- Where there any fatalities?
  Choose either "Yes" or "No."
- Where there any non-fatal injuries?
  Choose either "Yes" or "No."
- Where you involved in any other accidents within the last 3 years?
  Choose either "Yes" or "No."
- When was your next previous accident?
  
  MonthDayYear
  Date
- Describe the nature of your last accident.
- Where there any fatalities?
  Choose either "Yes" or "No."
- Where there any non-fatal injuries?
  Choose either "Yes" or "No."
- Where you involved in any other accidents within the last 3 years?
  Choose either "Yes" or "No."
- Have you been convicted or any traffic violations other than parking violations in the last 3 years?*
  Choose either "Yes" or "No."
- Location of last traffic violation for which you were convicted:
- Date of Conviction or Forfeiture:
  
  MonthDayYear
  Date
- Charge:
- Penalty:
- Any other convictions or forfeitures within the last 3 years?
  Choose either "Yes" or "No."
- Location of next recent traffic violation for which you were convicted:
- Date of Conviction or Forfeiture:
  
  MonthDayYear
  Date
- Charge:
- Penalty:
- Any other convictions or forfeitures within the last 3 years?
  Choose either "Yes" or "No."
- Location of third recent traffic violation for which you were convicted:
- Date of Conviction or Forfeiture:
  
  MonthDayYear
  Date
- Charge:
- Penalty:

Education
What is the highest grade that you completed in high school?
How many years have you completed in college?
What is the name of the last school you attended?

Qualifications
Current CDL Number or Driver's License Number*
State of Issue*
(Ex. OH, MS, KS, CT)
Class*
Expiration Date*

MonthDayYear
Date
Have you held a driver's license in any other state than the one you currently hold?*

YesNo
Give the license number and state for each license.
(Ex. 12345-OH)
Have you ever been denied a license, permit or privilege to operate a motor vehicle?*

YesNo
Explain why.
Has any license, permit, or privilege ever been suspended or revoked?*

YesNo
Explain why.

PLEASE READ AND SIGN
This certifies that this application was completed by me, type full name , and that all entries on it and information in it are true and complete to the best of my knowledge.

I, type full name, 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 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 liability in responding to inquiries and releasing information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
Signature
Sign here by typing your name if you are not using a touch screen enabled device.
Type your full name.
Date

MonthDayYear
Date
Should be Empty:

Truck Driver Application for Employment

Employment History

Driving Record

Education

Experience

Qualifications

PLEASE READ AND SIGN