Truck Driver Application

DRIVER APPLICATION

This application is designed to meet U.S. Department of Transportation (DOT) requirements under FMCSA regulations (49 CFR §391). All sections must be completed fully and accurately.
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 agree on the accuracy of the information.
Signature

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Position/Lane Applying For
General Information
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Were you at this address 3 years or more

YesNo
Please list prior 3 year addresses here and please be complete
Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Were you referred by anyone to apply for this position?

YesNo
Please list name
Explain ie; maiden name, name change
If hired, can you furnish proof you are eligible to work in the U.S.?*

YesNo
License Information
Have you held a VALID US license for the past 36 months?*

YesNo
License Class*
License Number*
State of Issue*
License expiration date*

MonthDayYear
Expiration date of DOT physical card

MonthDayYear
CDL Endorsements*

NoneTankerDoubles/TriplesHazmatX EndorsementTWIC
TWIC expiration date

MonthDayYear
Please list any licenses held in other states for the previous 5 years, include license numbers if you can.
Were you ever in the military?*

YesNo
EMPLOYMENT HISTORY

Past 10 years
Work History: Please list current, or most recent employment first.
DOT regulations require a complete 10-year employment history.
Start date*

MonthDayYear
Ending date*

MonthDayYear
Employer Name*
City, State*
Employer phone*

Area CodePhone Number
Position Held*
Reason for leaving*
Is this your current employer?*

YesNo
May we contact this employer at this time?*

YesNo
Was this a driving position?

YesNo
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

Area CodePhone Number
Was this a driving position?

YesNo
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

Area CodePhone Number
Reason for leaving
Was this a driving position

YesNo
Type of truck driven
Type of trailer
Trailer length
Number of states driven
Start Date

MonthDayYear
End Date

MonthDayYear
Employer Name
City and State
Position
Employer Phone

Area CodePhone Number
Reason for leaving
Was this a driving position

YesNo
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.
Additional Information
Have you had any moving violations in the last 5 years?*

YesNo
If yes, please list City, County and State, month, year and nature of offense and any fines involved
Please list miles over limit for speeding
Has your license ever been suspended?*

YesNo
If yes, please give date and length of supension. List reason why, city, county and state
List all details asked for
Have you had any accidents in the last 5 years?*

YesNo
If yes, please give date, explaination, city, county and state and if you received ticket/fine (amount)
Have you ever had a DUI, DWI, or OVI?*

YesNo
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?*

YesNo
If yes, please give date and nature of offense, city, county, state and any fines and time served
Please list EVERYTHING asked for per isurance requirements
By signing I agree I have read the above statements
Should be Empty:

General Information

License Information

EMPLOYMENT HISTORY

Additional Information