Platinum Materials - Commercial Driver Application

PLATINUM MATERIALS, LLC

DRIVER EMPLOYMENT APPLICATION

11 Gateway Blvd South, Suite 44, Savannah, GA 31419 | 912-713-7283

An Equal Opportunity Employer
Please complete in full or your application will not be considered.
GENERAL INFORMATION
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Date of Birth

MonthDayYear
Have you ever been known by any other name?
Please list name
Explain ie; maiden name, name change
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Were you at this address 3 years or more
Please list prior 3 year addresses here and please be complete
If hired, can you furnish proof you are eligible to work in the U.S.?
Are you at least 23 years of age or older?
LICENSE INFORMATION
Have you held a VALID US license for the past 36 months?
License Class
License Number
State of Issue
License expiration date

MonthDayYear
Expiration date of DOT medical card

MonthDayYear
CDL Endorsements
Hazmat expiration date

MonthDayYear
TWIC expiration date

MonthDayYear
No person who operates a commercial 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. Please list any licenses held in other states for the previous 3 years, include license numbers if you can.
Were you ever in the military?
Branch of service
Please list Dates of enlisment
Enlist date - Discharge date
EMPLOYMENT HISTORY

Work History: Please list current, or most recent employment first
Start date

MonthDayYear
Ending date

MonthDayYear
Employer Name
City, State
Employer phone
Format: (000) 000-0000.
Position Held
Reason for leaving
Is this your current employer?
May we contact this employer at this time?
Was this a driving position?
Type of truck
Type of trailer
Trailer length
Number of states driven
NEXT EMPLOYER
Start date

MonthDayYear
Ending date

MonthDayYear
Employer Name
City, State
Position Held
Reason for leaving
Employer phone
Format: (000) 000-0000.
Was this a driving position?
Type of truck
Type of trailer
Trailer length
Number of states driven
NEXT EMPLOYER
Starting date

MonthDayYear
Ending date

MonthDayYear
Employer Name
City, State
Position Held
Employer phone
Format: (000) 000-0000.
Reason for leaving
Was this a driving position
Type of truck driven
Type of trailer
Trailer length
Number of states driven
NEXT EMPLOYER
Start Date

MonthDayYear
End Date

MonthDayYear
Employer Name
City and State
Position
Employer Phone
Format: (000) 000-0000.
Reason for leaving
Was this a driving position
Type of truck driven
Type of trailer
Trailer length
Number of states driven
If you need additional space for past employment, please enter it here and include ALL information previously asked for.
BACKGROUND INFORMATION
Have you had any traffic violations in the last 3 years?
If yes, please list City, County and State, month, year, nature of offense, and any fines/penalties involved
Please list miles over limit for speeding
Has your license or permit ever been suspended or revoked?
If yes, please give date and length of suspension. List reason why, city, county, and state
List all details asked for
Have you had any accidents in the last 3 years?
If yes, please give date, explanation, city, county, state, and if there were any injuries or fatalities
Have you ever had a DUI, DWI, or OVI?
If yes, please list date of offense, jail time, fine, and/or suspension time.
We must have complete information to satisfy isusance carrier requirements.
Have you ever been convicted of a felony?
If yes, please give date and nature of offense, city, county, state, and any fines or time served
Please list EVERYTHING asked for per isurance requirements
Have you ever been convicted of a misdemeanor?
If yes, please list date, nature of offense, city, county and state, jail time, probation, or fines
Please list EVERYTHING asked for
EDUCATION
College

Name of College / Location (State)Years Attended
Did you graduate?
High School

Street Address

Street Address Line 2

Name of High School / Location (State)Years Attended

Postal / Zip Code
Did you graduate?
PROFESSIONAL REFERENCES
Name
Occupation

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to you
Phone Number
Format: (000) 000-0000.
Name
Occupation

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to you
Phone Number
Format: (000) 000-0000.
ADDITIONAL INFORMATION
Any other qualifications that you have and believe should be considered?
By signing I agree I have read the above statements
Should be Empty:

GENERAL INFORMATION

LICENSE INFORMATION

EMPLOYMENT HISTORY

NEXT EMPLOYER

BACKGROUND INFORMATION

EDUCATION

PROFESSIONAL REFERENCES

ADDITIONAL INFORMATION