Driver's Application for Employment

Additional Addresses
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."

Accidents
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."

Next Accident
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."

Traffic Convictions and Forfeitures for the Past 3 Years (Other than Parking Violations)
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."

Next Recent Conviction or Forfeiture
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."

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

Clear
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