Application Form

EMPLOYMENT APPLICATION

An Equal Opportunity Employer
Please fill out all sections. Only complete applications will be considered.
APPLICANT INFORMATION
Name of the Applicant

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.
Email
yourname@example.com
Date of Birth

MonthDayYear
Social Security #
Date of Application

MonthDayYear
Position Applied For
Date Available for Work

MonthDayYear
Can you provide proof of age?
Do you have legal right to work in the United States?

PREVIOUS THREE YEARS RESIDENCY

	ADDRESS	CITY	STATE	ZIP CODE	# OF YEARS AT ADDRESS
CURRENT
MAILING
PREVIOUS
PREVIOUS
PREVIOUS
PREVIOUS

LICENSE INFORMATION

No person who operates a commercial motor 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, the information for which is listed below. Include all licenses held for the past 3 years.

	STATE	LICENSE #	TYPE/CLASS	ENDORSEMENTS	EXPIRATION DATE
Current
PREVOIUSLY HELD LICENSES
PREVIOUS
PREVIOUS

DRIVING EXPERIENCE

	TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	DATE FROM	DATE TO	APPROX # OF MILES (TOTAL)
STRAIGHT TRUCK
TRACTOR & SEMI-TRAILER
TRACTOR & (2) TRAILERS
TRACTOR & TANKER
HEAVY HAUL

ACCIDENT RECORD FOR THE PAST 3 YEARS

	DATES (List most recent first)	NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.)	# FATALITIES	# INJURIES	CHEMICAL SPILLS (Y/N)
1
2
3
4

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

	DATE CONVICTED (Month/Year)	VIOLATION	STATE OF VIOLATION	PENALTY (Forfeited bond, collateral and/or points)
1
2
3
4

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

YesNo
Explain
Has any license, permit, or privilege ever been suspended or revoked?

YesNo
Explain
Upload Driver's license*

For verification process
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I certify that the information provided is accurate and my license is current and valid.
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. You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information
Are you now employed?

YesNo
Explain
Have you worked for this company before?

YesNo
Explain

CURRENT (MOST RECENT) EMPLOYER

	Please Fill
NAME
PHONE
ADDRESS
POSITION HELD
FROM (MO/YR)
TO (MO/YR)
REASON FOR LEAVING
SALARY
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)

SECOND (MOST RECENT) EMPLOYER

	Please Fill
NAME
PHONE
ADDRESS
POSITION HELD
FROM (MO/YR)
TO (MO/YR)
REASON FOR LEAVING
SALARY
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

YesNo
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

YesNo

THIRD (MOST RECENT) EMPLOYER

	Please Fill
NAME
PHONE
ADDRESS
POSITION HELD
FROM (MO/YR)
TO (MO/YR)
REASON FOR LEAVING
SALARY
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)

FOURTH (MOST RECENT) EMPLOYER

	Please Fill
NAME
PHONE
ADDRESS
POSITION HELD
FROM (MO/YR)
TO (MO/YR)
REASON FOR LEAVING
SALARY
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)

FIFTH (MOST RECENT) EMPLOYER

	Please Fill
NAME
PHONE
ADDRESS
POSITION HELD
FROM (MO/YR)
TO (MO/YR)
REASON FOR LEAVING
SALARY
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)

EDUCATION

	NAME & LOCATION	COURSE OF STUDY	YEARS COMPLETED	GRADUATE (Y/N)	DETAILS
High School
College
Other

OTHER QUALIFICATIONS
Please list any other qualifications that you have and which you believe should be considered.
Upload Resume (Optional)

Want to stand out? Share your resume for added context.
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TO BE READ AND SIGNED BY APPLICANT:

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 the information I provide regarding my current and/or prior 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.

I understand that I have the right to:
- Review information provided by current/previous employers;
- Have errors in the information corrected by previous employers, and for those previous employers to resend 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 agree on the accuracy of the information.
This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.
Applicant Signature

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Applicant Name (printed)
Date

MonthDayYear
Date

EMPLOYMENT APPLICATION

APPLICANT INFORMATION

LICENSE INFORMATION

EMPLOYMENT HISTORY

MVR Authorization

AUTHORIZATION TO OBTAIN MOTOR VEHICLE RECORD