Driver Application

Driver Application
Applicant Name*

First NameMiddle NameLast Name
Date of Application*

MonthDayYear
Date
Company
Email*
example@example.com
Social Security No.*
Phone Number*
Please enter a valid phone number.
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

TO BE READ AND SIGNED BY APPLICANT:

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 corrected information to the prospective employer; and
- Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot aggree on the accuracy of the information.
Signature:*

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Date of signature*

MonthDayYear
Please provide the following: (1) A copy of your Driver's License, (2) A copy of your Social Security card or another form of identification, and (3) A copy of your Medical card.*

Cancelof
Position(s) Applied for:*
List your addresses of residency for the past 3 years.
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Previous Addresses
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

End Previous Addresses
Do you have the legal authority to work in the United States?*
Date of Birth (Required for commercial drivers)*

MonthDayYear
Have you worked for this company before? If so, please state where, your dates of employment, what position you held, and your reason for leaving.*
Who referred you?*
Rate of pay expected:*
Have you ever been bonded? (Answer only if a job requirement.) If so, please state the name of bonding company.
Can you perform, with or without reasonable accommodation, the essential functions of the job (as described in the job description)?*

YesNo
Employment History
All driver applicants 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. Upload additional employer info above as necessary.)

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
Employer #1: Name
Employer #1: Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer #1: Contact Person and Phone Number
Employer #1: Dates Worked (included month & year of start, and month & year of end)
Employer #1: Position Held
Employer #1: Reason for Leaving
Employer #1: Were you subject to FMCSRs* while employed?

YesNo
Employer #1: 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?

YesNo

Employer #2
Employer #2: Name
Employer #2: Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer #2: Contact Person and Phone Number
Employer #2: Dates Worked (included month & year of start, and month & year of end)
Employer #2: Position Held
Employer #2: Reason for Leaving
Employer #2: Were you subject to FMCSRs* while employed?

YesNo
Employer #2: 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?

YesNo

Employer #3
Employer #3: Name
Employer #3: Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer #3: Contact Person and Phone Number
Employer #3: Dates Worked (included month & year of start, and month & year of end)
Employer #3: Position Held
Employer #3: Reason for Leaving
Employer #3: Were you subject to FMCSRs* while employed?

YesNo
Employer #3: 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?

YesNo

Employer #4
Employer #4: Name
Employer #4: Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer #4: Contact Person and Phone Number
Employer #4: Dates Worked (included month & year of start, and month & year of end)
Employer #4: Position Held
Employer #4: Reason for Leaving
Employer #4: Were you subject to FMCSRs* while employed?

YesNo
Employer #4: 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?

YesNo

Employer #5
Employer #5: Name
Employer #5: Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer #5: Contact Person and Phone Number
Employer #5: Dates Worked (included month & year of start, and month & year of end)
Employer #5: Position Held
Employer #5: Reason for Leaving
Employer #5: Were you subject to FMCSRs* while employed?

YesNo
Employer #5: 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?

YesNo

Employer #6
Employer #6: Name
Employer #6: Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer #6: Contact Person and Phone Number
Employer #6: Dates Worked (included month & year of start, and month & year of end)
Employer #6: Position Held
Employer #6: Reason for Leaving
Employer #6: Were you subject to FMCSRs* while employed?

YesNo
Employer #6: 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?

YesNo

Driver Application

Employment History

Accident Record

Traffic Convictions

Experience and Qualifications - Driver

Driving Experience

Experience and Qualifications - Other

Education