Employment Application

Employment Application

In accordance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, region, 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 authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I 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. I also understand that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employer 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 I have the right to:
• Review information provided by previous employer(s)
• Have errors in the information corrected by previous employer(s) and for those previous employer(s) to re-send the corrected information to the prospective employer
• Have a rebuttal statement attached to the alleged erroneous information that I, and the previous employer(s) cannot agree on the accuracy of the information.
Name*

First NameLast Name
Last 4 Of Social #*
Signature*
Date*

MonthDayYear
Date

EMPLOYMENT HISTORY

The Federal Motor Carrier Safety Regulations (49 CFR 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.

PLEASE INCLUDE 10 YEARS OF EMPLOYMENT HISTORY OR APPLICATION WILL NOT BE CONSIDERED, IF APPLICABLE.
CURRENT OR MOST RECENT EMPLOYMENT*
Phone # of Contact/Supervisor*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:*
Reason For Leaving*
Salary
Explain Any Gaps In Employment
Where you Subject to the FMCSR while employed:*

YesNo
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
If Currently Employed do you give permission to call for reference (A 'no' answer does not disqualify you from the application process)*

YesNo

NEXT EMPLOYER
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment
Where you Subject to the FMCSR while employed:

YesNo
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
NEXT EMPLOYER
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment
Where you Subject to the FMCSR while employed:

YesNo
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

NEXT EMPLOYER
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Salary
Explain Any Gaps In Employment
Where you Subject to the FMCSR while employed:

YesNo
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
NEXT EMPLOYER
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Held
Dates Employed:
Reason For Leaving
Type a question
Type a question
Salary
Explain Any Gaps In Employment
Where you Subject to the FMCSR while employed:

YesNo
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
If needed please upload more employment history for the 10 year requirement.

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ACCIDENT RECORD FOR THE PAST 3 YEARS-list most recent first

Rows	Date:	Nature of Accident	Number of Fatalities	Number of Injuries	Chemical Spills (Y/N)
-
-
-
-

Check this box if none

I do not have any accidents
Have you ever been denied a license, permit, or privilege to operate a motor vehicle? If yes please explain:

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS

Rows	Date	Violation	State of Violation	Penalty
-
-
-

Check this box if none

I do not have any traffic convictions or forfeitures
Has any license, permit or privilege ever been suspended or revoked? If yes please explain:

DRIVERS LICENSE OR PERMITS HELD IN THE PAST 3 YEARS*

Rows	STATE	LICENSE NUMBER	CLASS	ENDORSEMENT(S)	EXPIRATION DATE
-
-
-

How many years of CDL experience do you have?*
How many years of Truck/Trailer combo experience do you have?*

DRIVING EXPERIENCE- please list driving experience, if it doesn't apply put N/A *

Rows	YES	NO	TYPE OF EQUIPMENT (VAN/TANK/FLAT/DUMP/REEFER)	TOTAL MILES
STRAIGHT TRUCK
TRACTOR AND SEMI-TRAILER
TRACTOR-TWO TRAILERS
TRACTOR-THREE TRAILER
MOTOR-COACH-SCHOOL BUS MORE THAN 8 PASSENGERS
MOTOR-COACH-SCHOOL BUS MORE THAN 15 PASSENGERS

List States Operated In The Last 5 Years*
Which safe driving awards do you hold and from whom?
Please list any other qualifications that you have and which you believe should be considered.

EDUCATION *

Rows	NAME AND LOCATION	COURS OF STUDY	YEARS COMPLETED	GRADUATED (YES/NO)	ANY ADDITIONAL DETAILS
HIGH SCHOOL
COLLEGE
OTHER

PROFESSIONAL REFERENCES-please list at least 3*

Rows	FULL NAME	VALID PHONE NUMBER	YEARS KNOWN
-
-
-

PERSONAL REFERENCES-please list at least 3*

Rows	FULL NAME	VALID PHONE NUMBER	YEARS KNOWN
-
-
-

For Faster processing, please upload a copy of your drivers license*

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To be read and Signed by applicant*

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.

For Company Use:

Application Processing Record
Hire Date:

MonthDayYear
Position
Rejected Date:

MonthDayYear
Date
Rejection Summary
Signature/Name Of Processor
Title of Processor
Date Terminated

MonthDayYear
Date
Position
Select One

DismissedVoluntarily QuitOther
Summary Of Termination
Signature/Name Of Processor
Title of Processor
Should be Empty:

Employment Application

APPLICANT INFORMATION

PREVIOUS THREE YEARS OF RESIDENCY

For Company Use: