Commercial Driver Application
Company:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Application Information
Date:
-
Month
-
Day
Year
Date
Position applying for:
Please Select
Contractor
Driver
Contractor's Driver
Name:
First Name
Last Name
Phone Number:
Please enter a valid phone number.
Emergency Phone Number:
Please enter a valid phone number.
Email Address:
example@example.com
Age:
Date of Birth
-
Month
-
Day
Year
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:
-
Month
-
Day
Year
Date
Current & Previous Three Years Addresses:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Have You Worked For This Company Before?:
Please Select
Yes
No
If yes, give date - From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Education History
Please select the highest grade completed:
Please Select
Grade School: 1
Grade School: 2
Grade School: 3
Grade School: 4
Grade School: 5
Grade School: 6
Grade School: 7
Grade School: 8
Grade School: 9
Grade School: 10
Grade School: 11
Grade School: 12
College: 1
College: 2
College: 3
College: 4
Post Graduate: 1
Post Graduate: 2
Post Graduate: 3
Post Graduate: 4
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
City
State / Province
Postal / Zip Code
Reason for Leaving:
Company Phone Number:
Please enter a valid phone number.
Were you subject to the FMCSRs while employed here?:
Please Select
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?:
Please Select
Yes
No
Employment History - From Date:
To Date:
Present or Last Employer Name:
Position Held:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Leaving:
Company Phone Number:
Please enter a valid phone number.
Were you subject to the FMCSRs while employed here?:
Please Select
Yes
No
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?
Please Select
Yes
No
Employment History - From Date:
To Date:
Present of Last Employer Name:
Position Held:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Leaving:
Company Phone Number:
Please enter a valid phone number.
Were you subject to the FMCSRs while employed here?
Please Select
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?
Please Select
Yes
No
Employment History - From Date:
To Date:
Present or Last Employer Name:
Position Held:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Leaving:
Company Phone Number:
Please enter a valid phone number.
Were you subject to the FMCSRs while employed here?
Please Select
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?
Please Select
Yes
No
Employment History - From Date:
To Date:
Present or Last Employer Name:
Position Held:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Leaving:
Company Phone Number:
Please enter a valid phone number.
Were you subject to the FMCSRs while employed here?
Please Select
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?
Please Select
Yes
No
Driving Experience
Class of Equipment
Straight Truck-From Date:
-
Month
-
Day
Year
Date
To Date:
-
Month
-
Day
Year
Date
Approximate Number of Miles:
Tractor & Semi/Trailer-From Date:
-
Month
-
Day
Year
Date
To Date:
-
Month
-
Day
Year
Date
Approximate Number of Miles:
Tractor & Two Trailers-From Date:
-
Month
-
Day
Year
Date
To Date:
-
Month
-
Day
Year
Date
Approximate Number of Miles:
Tractor & Triple Trailers-From Date:
-
Month
-
Day
Year
Date
To Date:
-
Month
-
Day
Year
Date
Approximate Number of Miles:
Other-From Date:
-
Month
-
Day
Year
Date
To Date:
-
Month
-
Day
Year
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:
-
Month
-
Day
Year
Date
Nature of Accidents (Head on, rear end, etc):
Location of Accident Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Fatalities:
Number of People Injured:
Accident Record-Date of Accident:
-
Month
-
Day
Year
Date
Nature of Accidents (Head on, rear end, etc):
Location of Accident Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Fatalities:
Number of People Injured:
Accident Record-Date of Accident:
-
Month
-
Day
Year
Date
Nature of Accidents (Head on, rear end, etc):
Location of Accident Address:
Street Address
Street Address Line 2
City
State / 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:
-
Month
-
Day
Year
Date
Location Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Charge:
Penalty:
Traffic Convictions Date:
-
Month
-
Day
Year
Date
Location Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Charge:
Penalty:
Traffic Convictions Date:
-
Month
-
Day
Year
Date
Location Address:
Street Address
Street Address Line 2
City
State / 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:
-
Month
-
Day
Year
Date
Driver's License (State):
License Number:
License Class (A, B, C, D, G or M):
Endorsements:
Expiration Date:
-
Month
-
Day
Year
Date
Driver License (State):
Driver's License Number:
License Class (A, B, C, D, G or M):
Endorsements:
Expiration Date:
-
Month
-
Day
Year
Date
Driver's License (State):
Driver License Number:
License Class (A, B, C, D, G or M):
Endorsements:
Expiration Date:
-
Month
-
Day
Year
Date
Driver's License (State):
Driver's License Number:
License Class (A, B, C, D, G or M):
Endorsements:
Expiration Date:
-
Month
-
Day
Year
Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle?:
Please Select
Yes
No
Has any license, permit or privilege ever been suspended or revoked?:
Please Select
Yes
No
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)?"
Please Select
Yes
No
Have you ever been convicted of a felony?:
Please Select
Yes
No
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:
-
Month
-
Day
Year
Date
Submit
Should be Empty: