DRIVER EMPLOYMENT APPLICATION Aegis Oilfield Services
An Equal Opportunity Employer
Personal information
First Name
*
as it appears on your DL
Middle Name
As it appears on your DL
Last Name
*
As it appears on your DL
Suffix
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Jr.
Sr.
I.
II.
III.
IV.
V.
SS#
*
Date of Birth
*
-
Month
-
Day
Year
Date
Applying for
Please Select
Company driver
Owner Operator
Driver for Owner Operator
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Primary Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Has this been your Primary address for 3 years or more
*
Please Select
Yes
No
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Confirm your email
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Preferred choice of Contact
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Primary Phone
Cell Phone
Email
Text Message
Best time to contact you
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Any
Morning
Afternoon
Night
Emergency contact
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First Name
Last Name
Phone Number for emergency contact
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have legal right to work in the United States?
*
Please Select
Yes
No
Can you read and speak the English language sufficiently to converse with the general public, to understand highway traffic signs and signals in the English language, to respond to official inquiries, and to make entries on reports and records;
*
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Yes
No
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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;
License number
*
State issued
*
Expiration date
*
endorsements/restrictions
*
DL Front
*
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DL Back
*
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Have you had another DL in the last 3 years
*
Please Select
yes
No
Previous drivers license
number
state
HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE?
*
Please Select
Yes
No
HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED?
*
Please Select
Yes
No
List any Accident Records for Past 3 Years
List any traffic Convictions & Forfeitures for Past 3 Years
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Driving 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.
Employer
*
From
*
-
Month
-
Day
Year
Date
To
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED?
Please Select
Yes
No
WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
Please Select
Yes
No
Employer
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED?
Please Select
Yes
No
WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
Please Select
Yes
No
Employer
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED?
Please Select
Yes
No
WAS YOUR JOB DESIGNATED AS A SAFETY SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
Please Select
Yes
No
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Fair Credit Reporting Act Disclosure Statement
In accordance with the provisions of Section 604 (b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. Your employer may obtain this information from Accufax, Equifax, Transunion, Experion or other vendors of information services
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