APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT
(FIRST)
(MIDDLE)
(Maiden Name if any)
(LAST)
ADDRESS
(STREET)
(CITY)
(STATE & ZIP CODE)
HOW LONG?
DATE OF BIRTH

MonthDayYear
Date
SOCIAL SECURITY NO
HIRE DATE

MonthDayYear
Date
TELEPHONE NUMBER
E MAIL ADDRESS
example@example.com
PREVIOUS THREE YEARS RESIDENCY
(STREET)
(CITY)
(STATE & ZIP CODE)
# YEARS
(STREET)
(CITY)
(STATE & ZIP CODE)
(STREET)
(CITY)
(STATE & ZIP CODE)
Driving Experience
Straight Truck
Type of Equipment(Van,Tank,Flat, ETC):
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Aprox. No. of Miles (Total)
Tractor and Semi-Trailer
Type of Equipment(Van,Tank,Flat, ETC):
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Aprox. No. of Miles (Total)
TRACTOR TWO TRAILERS
Type of Equipment(Van,Tank,Flat, ETC):
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Aprox. No. of Miles (Total)
License Information:
STATE
LICENSE NO
TYPE
EXPIRATION DATE

MonthDayYear
Date
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE:
Date:

MonthDayYear
Date
Nature of Accident(Head-On, Rear-End, Upset):
Number of Fatalities:
Number of Injuries:
Chemical Spills:

YesNo
Date:

MonthDayYear
Date
Nature of Accident(Head-On, Rear-End, Upset):
Number of Fatalities:
Number of Injuries:
Chemical Spills:

YesNo
Date:

MonthDayYear
Date
Nature of Accident(Head-On, Rear-End, Upset):
Number of Fatalities:
Number of Injuries:
Chemical Spills:

YesNo
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
Date Convicted

MonthDayYear
Date
Violation
State of Violation Location:
Penalty
Date Convicted

MonthDayYear
Date
Violation
State of Violation Location:
Penalty
Date Convicted

MonthDayYear
Date
Violation
State of Violation Location:
Penalty
Have you ever been denied a license, permit or privilege to operate a motor vehicle?

YesNo
If yes, explain
Have you ever been denied a license, permit or privilege to operate a motor vehicle?

YesNo
If yes, explain
EMPLOYMENT RECORD (ATTACH SHEET IF MORE SPACE IS NEEDED)

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record Must list the complete mailing address: street number and name, city, state and zip code
LAST EMPLOYER NAME
ADDRESS
PHONE
POSITION HELD
FROM
TO
SALARY
REASONS FOR LEAVING
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES (MONTH/YEAR) AND REASON
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES (MONTH/YEAR)

MonthDayYear
Date
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes
Yes
Was the previous job position designated as a safety sensitive function in any DOT regulated made subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?YesNo
Yes
SECOND LAST EMPLOYER NAME
ADDRESS
PHONE
POSITION HELD
FROM
TO
SALARY
REASONS FOR LEAVING
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES (MONTH/YEAR) AND REASON
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES (MONTH/YEAR)

MonthDayYear
Date
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes

Was the previous job position designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 407YesNo
Yes
THIRD LAST EMPLOYER NAME
NAME
ADDRESS
PHONE
POSITION HELD
FROM
TO
SALARY
REASONS FOR LEAVING
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES (MONTH/YEAR) AND REASON
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES (MONTH/YEAR)

MonthDayYear
Date
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 407YesNo
Yes
No
TO BE READ AND SIGNED BY APPLICANT
DATE

MonthDayYear
Date
APPLICANT'S SIGNATURE

Clear
This certifies that I completed this application and that all entries on it and information in 4 are true and complete to the best of my knowledge
DATE

MonthDayYear
Date
APPLICANTS SIGNATURE

Clear
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations
Should be Empty:

APPLICATION FOR EMPLOYMENT

ADDRESS

Driving Experience

Straight Truck

Tractor and Semi-Trailer

TRACTOR TWO TRAILERS

License Information:

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE:

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES (MONTH/YEAR) AND REASON

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES (MONTH/YEAR) AND REASON

THIRD LAST EMPLOYER NAME

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES (MONTH/YEAR) AND REASON

TO BE READ AND SIGNED BY APPLICANT