PC Transport Driver Application Form

DRIVERS APPLICATION FOR EMPLOYMENT

Please complete the form below to apply for a driver position with us.
Full Name*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Did you move within the last 3 years?*
Previous Address 1

Street Address

Street Address Line 2

CityState

Zip Code
Previous Address 2

Street Address

Street Address Line 2

CityState

Zip Code
Previous Address 3

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Resume

Cancelof
Do you have legal authority to work in the United States?*
Have you worked for this company before?*
Where?
From

MonthDayYear
Date
To

MonthDayYear
Date
Position
Reason for leaving
Who referred you?
Rate of pay expected ($USD)
Have you ever bonded?*
Name of bonding company
Can you perform, with or without reasonable accommodation, the essential functions of the job (as described in the attached job description)?*

Employment History
All driver applications to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code.

Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle.

NOTE: List employers in reverse order starting with the most recent.
Employer 1*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
From*

MonthDayYear
Date
Are you currently still employed here?*
To

MonthDayYear
Date
Contact Person*
Phone Number*
Please enter a valid phone number.
Position Held*
Reason for leaving
Were you subject to the FMCSRs while employed?*
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?*
Do you have another employer to add?*

Employer 2*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Contact Person*
Phone Number*
Please enter a valid phone number.
Position Held*
Reason for leaving
Were you subject to the FMCSRs while employed?*
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?*
Do you have another employer to add?*

Employer 3*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Contact Person*
Phone Number*
Please enter a valid phone number.
Position Held*
Reason for leaving
Were you subject to the FMCSRs while employed?*
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?*
Do you have another employer to add?*

Employer 4*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Contact Person*
Phone Number*
Please enter a valid phone number.
Position Held*
Reason for leaving
Were you subject to the FMCSRs while employed?*
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?*
Do you have another employer to add?*

Employer 5*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Contact Person*
Phone Number*
Please enter a valid phone number.
Position Held*
Reason for leaving
Were you subject to the FMCSRs while employed?*
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?*
Do you have another employer to add?*

Employer 6*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Contact Person*
Phone Number*
Please enter a valid phone number.
Position Held*
Reason for leaving
Were you subject to the FMCSRs while employed?*
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?*
Do you have another employer to add?*

Employer 7*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Contact Person*
Phone Number*
Please enter a valid phone number.
Position Held*
Reason for leaving
Were you subject to the FMCSRs while employed?*
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?*

Accident Record

For the past 3 years or more.
Have you had any accidents in the past 3 years?*
Date of accident

MonthDayYear
Date
Nature of accident (head-on, rear-end, upset, etc.)
Were there fatalities?
Number of fatalities
Put 0 if unsure of actual count
Were there any injuries?
Number of injuries
Put 0 if unsure of actual count
Was there hazardous material spilled?
Do you have another accident to report?*

Accident 2
Date of accident

MonthDayYear
Date
Nature of accident (head-on, rear-end, upset, etc.)
Were there fatalities?
Number of fatalities
Put 0 if unsure of actual count
Were there any injuries?
Number of injuries
Put 0 if unsure of actual count
Was there hazardous material spilled?
Do you have another accident to report?*

Accident 3
Date of accident

MonthDayYear
Date
Nature of accident (head-on, rear-end, upset, etc.)
Were there fatalities?
Number of fatalities
Put 0 if unsure of actual count
Were there any injuries?
Number of injuries
Put 0 if unsure of actual count
Was there hazardous material spilled?

Traffic Convictions

For the past 3 years. Do not include parking violations.
Have you had any traffic convictions or violations in the last 3 years (exclude parking violations).*
Location
Date

MonthDayYear
Date
Charge
Penalty
Do you have another violation or conviction?
Location
Date

MonthDayYear
Date
Charge
Penalty
Do you have another violation or conviction?
Location
Date

MonthDayYear
Date
Charge
Penalty

Experience and Qualifications

Please list your drivers licenses held within the last 3 years below.
State*
License No.*
Expiration Date*

MonthDayYear
Date
Class*
Endorsement(s)*
Do you have another driver's license to add?*
State
License No.
Expiration Date

MonthDayYear
Date
Class
Endorsement(s)
Do you have another driver's license to add?
State
License No.
Expiration Date

MonthDayYear
Date
Class
Endorsement(s)
Do you have another driver's license to add?
State
License No.
Expiration Date

MonthDayYear
Date
Class
Endorsement(s)
Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
Details
Has any license, permit or privilege ever been suspended or revoked?*
Details

Driving Experience

Select yes or no for the following types of experience.
Straight Truck Experience?*
Type of Equipment
From

MonthDayYear
Date
To

MonthDayYear
Date
Approximate Number of Miles
Put 0 if unsure of actual count
Tractor & Semi-Trailer Experience?*
Type of Equipment
From

MonthDayYear
Date
To

MonthDayYear
Date
Approximate Number of Miles
Put 0 if unsure of actual count
Tractor - Two Trailer Experience?*
Type of Equipment
From

MonthDayYear
Date
To

MonthDayYear
Date
Approximate Number of Miles
Put 0 if unsure of actual count
Tractor - Three Trailer Experience?*
Type of Equipment
From

MonthDayYear
Date
To

MonthDayYear
Date
Approximate Number of Miles
Put 0 if unsure of actual count
Motorcoach - School Bus (less than 15 passengers) Experience?*
Approximate Number of Miles
Put 0 if unsure of actual count
From

MonthDayYear
Date
To

MonthDayYear
Date
Motorcoach - School Bus (more than 15 passengers) Experience?*
Approximate Number of Miles
Put 0 if unsure of actual count
From

MonthDayYear
Date
To

MonthDayYear
Date
Select states operated in for the last five years*
Use the "Ctrl" key to highlight multiple states
List special courses or training that will help you as a driver

0/500
List safe driving awards that you hold and from whom

0/500
List any trucking, transportation, or other experience that may help in your work for this company.

0/500
List special equipment or technical materials you can work with (other than those already listed)

0/500

Education
Did you graduate high school?*
Highest grade completed
Did you attend or graduate college?*
Last school attended name*
Address

Street Address

Street Address Line 2

CityState

Zip Code

Complete Application
I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:
- Review information provided by previous employers.
- Have errors in the information corrected by previous employers and for those previous employers to re-send the correct 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 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*

Powered by Jotform SignClear
Signed Date*

MonthDayYear
Date
Should be Empty:

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

DRIVERS APPLICATION FOR EMPLOYMENT

Employment History

Accident Record

Accident 2

Accident 3

Traffic Convictions

Experience and Qualifications

Driving Experience

Education

Complete Application