Driver Employment Application
Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Social Security #:
Email:
example@example.com
Date of Application:
-
Month
-
Day
Year
Date
Date Available to Work:
-
Month
-
Day
Year
Date
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Position:
Company Driver
Independent Contractor
Do you have the legal right to work in the US?
Yes
No
Previous two years of residency
Current
Address:
Street Address:
Street Address Line 2:
City:
State / Province:
Postal / Zip Code:
Number of years at this address:
Previous:
Street Address:
Street Address Line 2:
City:
State / Province:
Postal / Zip Code:
Number of years at this address:
Previous:
Street Address:
Street Address Line 2:
City:
State / Province:
Postal / Zip Code:
Number of years at this address:
Drivers License Information
No person who operates a commercial motor vehicle shall at any time have more than on 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 issued:
CDL / Driver's License Number:
Endorsements:
License Expiration Date:
-
Month
-
Day
Year
Date
Previously Held Licenses:
Previously Held Licenses:
Previously Held Licenses:
Driver Experience
Type of Equipment ( Van, Tank, Flat, Sprinter, Etc.)
Van
Tank
Flat
Sprinter
Other
If other please specify:
Years of Driving:
Please Select
0 to 2 Years
3 to 5 Years
Other
Check to Confirm:
All drivers must be available for pickups and deliveries 24/7.
All drivers must be available to deliver nationwide.
Vehicle Information
For all independent contractors
What type of vehicle do you own?
Cargo Van
Sprinter Van
Box Truck
Van
Flat
Year:
Vehicle must be a 2014 or newer.
Make:
Model:
Vin Number:
Tag Number:
Accident Record For The Past 3 Years
Have you had any accidents within the last 3 years?
yes
No
If yes, please specify Dates, Nature of Accident (Head-on, Rear-end, # Fatalities, # Injuries, Chemical Spills.
Have you had any Traffic Convictions and Forfeitures for the Past 3 years (Other than parking violations)?
Yes
No
If yes, Please specify Date of conviction,(month/year), violation, State of violation, Penalty ( Forfeited Bond, Collateral and/ or Points)
Required Questions
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes
No
Has a license, permit or privilege ever been suspended or revoked?
Yes
No
Have you ever been convicted of any criminal act involving the use of CMV or while driving a CMV?
Yes
No
Have you ever been convicted of any law violation? ( Include ANY pleas of "Guitly" or "No Contest" except for minor traffic violation?
Yes
No
If you answered "Yes" to Any of the above 4 questions, applicant Must make a statement of explanation.
Education
High School:
Name and Location
Years Completed:
Graduate:
Yes
No
College:
Name and Location
Years Completed:
Graduate:
Yes
No
Other:
Name and Location
Years Completed:
Graduate:
Yes
No
Employment History
391.21(b)(10) A list of the names and addresses of the applicant's employers during the 3 years proceeding the date the application is submitted, together with the date's he/she was employed by, and his/her reason for leaving the employ of, each employer. (b)(11) For those drivers applying to operate a commercial motor vehicle as defined by Part 383 of the subchapter, a list of the names and addresses of the applicant's employers during the 7 year period preceding the 3 years contained in paragraph (b)(10) of this section for which the applicant was an operator of a commercial motor vehicle, together with the dates of employment and the reasons for leaving such employment.
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Current or Most Recent Employer
Business Name:
Name of Supervisor:
Employment Start Date:
-
Month
-
Day
Year
Date
Employment End Date:
-
Month
-
Day
Year
Date
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
May we contact?
Yes
No
Address:
Street Address:
Street Address Line 2:
City:
State / Province:
Postal / Zip Code:
Current / Last position Title:
Reason for Leaving:
Were you ever employed in a safety sensitive function subject to DOT Drug & Alcohol Testing?
Yes
No
Were you subject to Federal Motor carrier Safety Regulations?
Yes
No
Next Previous Employer
Business Name:
Name of Supervisor:
Employment Start Date:
-
Month
-
Day
Year
Date
Employment End Date:
-
Month
-
Day
Year
Date
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
May we contact
Yes
No
Address:
Street Address:
Street Address Line 2:
City:
State / Province:
Postal / Zip Code:
Position:
Reason for Leaving:
Were you ever employed in a safety sensitive function subject to DOT Drug & Alcohol testing?
Yes
NO
Were you subject to Federal Moto Carrier Safety Regulations?
Yes
No
Next Previous Employer
Business Name:
Name of Supervisor:
Employment Start Date:
-
Month
-
Day
Year
Date
Employment End Date:
-
Month
-
Day
Year
Date
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
May we contact?
Yes
No
Address:
Street Address:
Street Address Line 2:
City:
State / Province:
Postal / Zip Code:
Position:
Reason for Leaving:
Were you ever employed in a safety sensitive function subject to DOT Drug & Alcohol testing?
Yes
NO
Were you subject to Federal Motor Carrier Safety Regulations?
Yes
No
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 ALLEDGED 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 FEDRAL MOTOR CARRIER SAFETY REGULATIONS.
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