Commercial Driver Application

Commercial Driver Application
Company:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Application Information
Date:

MonthDayYear
Date
Position applying for:
Name:

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

MonthDayYear
Date
Social Security Number:
(The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.)
Physical Exam Expiration Date:

MonthDayYear
Date
Current & Previous Three Years Addresses:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Have You Worked For This Company Before?:
If yes, give date - From:

MonthDayYear
Date
To:

MonthDayYear
Date
Education History
Please select the highest grade completed:
Employment History

Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years.
Employment History - From Date:
To Date:
Present or Last Employer:
Position Held:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Leaving:
Company Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Were you subject to the FMCSRs while employed here?:
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?:
Employment History - From Date:
To Date:
Present or Last Employer Name:
Position Held:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Leaving:
Company Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Were you subject to the FMCSRs while employed here?:
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing reuirements of 49 CFR Part 40?
Employment History - From Date:
To Date:
Present of Last Employer Name:
Position Held:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Leaving:
Company Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Were you subject to the FMCSRs while employed here?
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?
Employment History - From Date:
To Date:
Present or Last Employer Name:
Position Held:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Leaving:
Company Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Were you subject to the FMCSRs while employed here?
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?
Employment History - From Date:
To Date:
Present or Last Employer Name:
Position Held:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Leaving:
Company Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Were you subject to the FMCSRs while employed here?
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?
Driving Experience

Class of Equipment
Straight Truck-From Date:

MonthDayYear
Date
To Date:

MonthDayYear
Date
Approximate Number of Miles:
Tractor & Semi/Trailer-From Date:

MonthDayYear
Date
To Date:

MonthDayYear
Date
Approximate Number of Miles:
Tractor & Two Trailers-From Date:

MonthDayYear
Date
To Date:

MonthDayYear
Date
Approximate Number of Miles:
Tractor & Triple Trailers-From Date:

MonthDayYear
Date
To Date:

MonthDayYear
Date
Approximate Number of Miles:
Other-From Date:

MonthDayYear
Date
To Date:

MonthDayYear
Date
Approximate Number of Miles:
List States operated in, for the last five (5) years:
List special courses/training completed (PTD/DDC. HAZMAT, ETC):
List any Safe Driving Awards you hold and from whom:
Accident Record for the past three (3) years:
Accident Record-Date of Accident:

MonthDayYear
Date
Nature of Accidents (Head on, rear end, etc):
Location of Accident Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Fatalities:
Number of People Injured:
Accident Record-Date of Accident:

MonthDayYear
Date
Nature of Accidents (Head on, rear end, etc):
Location of Accident Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Fatalities:
Number of People Injured:
Accident Record-Date of Accident:

MonthDayYear
Date
Nature of Accidents (Head on, rear end, etc):
Location of Accident Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Fatalities:
Number of People Injured:
Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):
Traffic Convictions Date:

MonthDayYear
Date
Location Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Charge:
Penalty:
Traffic Convictions Date:

MonthDayYear
Date
Location Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Charge:
Penalty:
Traffic Convictions Date:

MonthDayYear
Date
Location Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Charge:
Penalty:
Driver's License (list each driver's license held in the past three (3) years:
Driver's License (State):
License Number:
License Class (A, B, C, D, G or M):
Endorsements:
Expiration Date:

MonthDayYear
Date
Driver's License (State):
License Number:
License Class (A, B, C, D, G or M):
Endorsements:
Expiration Date:

MonthDayYear
Date
Driver License (State):
Driver's License Number:
License Class (A, B, C, D, G or M):
Endorsements:
Expiration Date:

MonthDayYear
Date
Driver's License (State):
Driver License Number:
License Class (A, B, C, D, G or M):
Endorsements:
Expiration Date:

MonthDayYear
Date
Driver's License (State):
Driver's License Number:
License Class (A, B, C, D, G or M):
Endorsements:
Expiration Date:

MonthDayYear
Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle?:
Has any license, permit or privilege ever been suspended or revoked?:
Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?"
Have you ever been convicted of a felony?:
If the answers to any questions listed above are "yes", give details:
Job References

List three (3) persons for references other than family members, who have knowledge of your safety habits.
To Be Read and Signed by Applicant:

* - It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. * - It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to obtain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information. * - It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. * - I agree to furnish such additional information and complete such examinations as may be required to complete my application file. * - It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant. * - It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. * - 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:
Date:

MonthDayYear
Date
Should be Empty:

Commercial Driver Application

Application Information

Education History

Employment History

Driving Experience

Job References

To Be Read and Signed by Applicant: