DRIVER EMPLOYMENT APPLICATION

DRIVER EMPLOYMENT APPLICATION

Southern Eagle Distributing is located in Fort Pierce, Florida. We are an equal opportunity employer. If you are interested in becoming a delivery driver please click next to start our Driver Employment Application

PREVIOUS THREE YEARS RESIDENCY
CURRENT ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PREVIOUS ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PREVIOUS ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PREVIOUS ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

LICENSE INFORMATION

No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.
STATE*
LICENSE #*
TYPE/CLASS*
EXPIRATION DATE*

MonthDayYear
Date
ENDORSEMENT*
PREVIOUS HELD LICENSES
PREVIOUS STATE
PREVIOUS LICENSE #
PREVIOUS TYPE/CLASS
PREVIOUS EXPIRATION DATE

MonthDayYear
Date
PREVIOUS ENDORSEMENT
PREVIOUS STATE
PREVIOUS LICENSE #
PREVIOUS TYPE/CLASS
PREVIOUS EXPIRATION DATE

MonthDayYear
Date
PREVIOUS ENDORSEMENT

DRIVING EXPERIENCE
CLASS OF EQUIPMENT*
TYPE OF EQUIPMENT *
(VAN, TANK, FLAT, ETC...)
APPROX. # OF MILES (TOTAL)*
DATE FROM*

MonthDayYear
Date
DATE TO*

MonthDayYear
Date
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT
(VAN, TANK, FLAT, ETC...)
APPROX. # OF MILES (TOTAL)
DATE FROM

MonthDayYear
Date
DATE TO

MonthDayYear
Date
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT
(VAN, TANK, FLAT, ETC...)
APPROX. # OF MILES (TOTAL)
DATE FROM

MonthDayYear
Date
DATE TO

MonthDayYear
Date
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT
(VAN, TANK, FLAT, ETC...)
APPROX. # OF MILES (TOTAL)
DATE TO

MonthDayYear
Date
DATE FROM

MonthDayYear
Date

ACCIDENT RECORD FOR THE PAST 3 YEARS
HAVE YOU HAD AN ACCIDENT IN THE PAST 3 YEARS?*

I DO NOT have any accidents in the past 3 years (if checked no accidents, please skip below and click next)Yes I had an accident/s in the past 3 years (must fill below form before clicking next)
DATE OF ACCIDENT

MonthDayYear
List most recent accident date first
NATURE OF ACCIDENT
(Head-On, Rear-end, Upset, Etc...)
FATALITIES #
(Head-On, Rear-end, Upset, Etc...)
INJURIES #
(Head-On, Rear-end, Upset, Etc...)
Chemical Spills?

YesNo
DATE OF ACCIDENT

MonthDayYear
Second most recent accident date
NATURE OF ACCIDENT
(Head-On, Rear-end, Upset, Etc...)
FATALITIES #
(Head-On, Rear-end, Upset, Etc...)
INJURIES #
(Head-On, Rear-end, Upset, Etc...)
Chemical Spills?

YesNo
DATE OF ACCIDENT

MonthDayYear
Third most recent accident date
NATURE OF ACCIDENT
(Head-On, Rear-end, Upset, Etc...)
FATALITIES #
(Head-On, Rear-end, Upset, Etc...)
INJURIES #
(Head-On, Rear-end, Upset, Etc...)
Chemical Spills?

YesNo

TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 3 YEARS
HAVE YOU HAD A CONVICTION/FORFEITURE IN THE PAST 3 YEARS?*

I DO NOT have any conviction/forfeitures in the past 3 years (if checked no, please skip below and click next)Yes I had a conviction/forfeiture in the past 3 years (must fill below form before clicking next)
DATE CONVICTED

MonthDayYear
List most recent accident date first
VIOLATION
STATE OF VIOLATION
PENALTY
(Forfeited bond, Collateral and/or Points)
DATE CONVICTED

MonthDayYear
List most recent accident date first
VIOLATION
STATE OF VIOLATION
PENALTY
(Forfeited bond, Collateral and/or Points)
DATE CONVICTED

MonthDayYear
List most recent accident date first
VIOLATION
STATE OF VIOLATION
PENALTY
(Forfeited bond, Collateral and/or Points)
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*

YesNo
If Yes, Please Explain:
Has any license, permit or privilege ever been suspended or revoke?*

YesNo
If Yes, Please Explain:

EMPLOYMENT HISTORY

The Federal Motor Carrier Safety Regulations (49 CF 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.
Current (Most Recent) Employer
Current (Most Recent) Employer Name*
Current (Most Recent) Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current (Most Recent) Employer Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Position Held*
Employment Started*

MonthDayYear
Date
Employment Ended*

MonthDayYear
Date
Reason for Leaving?*
Explain any gaps in employment (include month, year and reason)*
Second (Most Recent) Employer
Second (Most Recent) Employer Name
Second (Most Recent) Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Second (Most Recent) Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Position Held
Employment Started

MonthDayYear
Date
Employment Ended

MonthDayYear
Date
Reason for Leaving?
Explain any gaps in employment (include month, year and reason)
Third (Most Recent) Employer
Third (Most Recent) Employer Name
Third (Most Recent) Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Third (Most Recent) Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Position Held
Employment Started

MonthDayYear
Date
Employment Ended

MonthDayYear
Date
Reason for Leaving?
Explain any gaps in employment (include month, year and reason)

EDUCATION
School Type*
School Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Course of Study
Graduated?

YesNo
Details
School Type
School Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Course of Study
Graduated?

YesNo
Details

OTHER QUALIFICATIONS
Please list any other qualifications that you have and which you believe should be considered

PLEASE READ AND SIGN
I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 discharge. also understand that I am required to abide by all rules and regulations of the Company.

understand that the information provide regarding my current and or prior employers may be used, and those employers) will be contacted for the purpose of investigating my safety performance history as required by 49 CF 391.23. I understand that have the right to:
- Review information provided by current/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;
- Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.
Name*

First NameLast Name
Signature*
Date Signed*

MonthDayYear
Date
Should be Empty:

DRIVER EMPLOYMENT APPLICATION

APPLICANT INFORMATION

PREVIOUS THREE YEARS RESIDENCY

LICENSE INFORMATION

PREVIOUS HELD LICENSES

DRIVING EXPERIENCE

ACCIDENT RECORD FOR THE PAST 3 YEARS

TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 3 YEARS

EMPLOYMENT HISTORY

Current (Most Recent) Employer

Second (Most Recent) Employer

Third (Most Recent) Employer

EDUCATION

OTHER QUALIFICATIONS

PLEASE READ AND SIGN