Cusumano & Sons, Inc. Driver Employment Application

Cusumano & Sons, Inc. Driver Employment Application

826 Harrison Street Mount Vernon, IL 62864 (618)244-0198
An Equal Opportunity Employer

This application is in accordance with FMCSR 49 CFR 391.21.
General Information
Date of Application

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Full Legal Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Per FMCSA regulations, you must be at least 21 to drive a CMV in interstate commerce. Are you 21 or over?
Position Applied For
Date Available for Work

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please provide your previous three years of residency.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Address #2, if applicable

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Address #3, if applicable

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you been employed with us before?
If Yes, provide the approximate time frame of your employment and your reason for leaving.
Have you been convicted of a felony within the last seven years? (Conviction will not necessarily disqualify an applicant from employment)
If Yes, please explain
License Information

No person who operates a commerical 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.
License Number
Issuing State
Type/Class
List Endorsements or 'none'
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Driving Experience

Please list all applicable professional driving experience.
Driving Experience #1
Class of Equipment

Other
Type of Equipment (Van, Tank, Flat, Etc.)
Date Started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Ended

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Approximate Number of Miles Driven
Driving Experience #2, if applicable
Class of Equipment

Other
Type of Equipment (Van, Tank, Flat, Etc.)
Date Started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Ended

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Approximate Number of Miles Driven
Driving Experience #3, if applicable
Class of Equipment

Other
Type of Equipment (Van, Tank, Flat, Etc.)
Date Started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Ended

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Approximate Number of Miles Driven
Accident Record for the Past 3 Years
Please select one
Date of Accident #1, if applicable

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Nature of Accident (Head-on, rear-end, upset, etc.)
Number of Fatalities
Number of Injuries
Was there a chemical spill?
Date of Accident #2, if applicable

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Nature of Accident (Head-on, rear-end, upset, etc.)
Number of Fatalities
Number of Injuries
Was there a chemical spill?
Traffic Convictions and Forfeitures for the Past 3 Years (other than parking violations)
Please select one
Date Convicted

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Violation
State of Violation
Penalty (Forfeited bond, collateral, and/or points)
Date Convicted

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Violation
State of Violation
Penalty (Forfeited bond, collateral, and/or points)
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
If Yes, please explain
Has any license, permit, or privilege ever been suspended or revoked?
If yes, please explain
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 years. In addition, if you have previously driven a commercial vehicle, you must provide employment history for an additional seven years. Explain any employment gaps longer than one month. Start with your last or current position, including any military experience, and work backwards.
Most Recent Employer
Are you currently employed there?
Employer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held
Dates of Employment
Reason for Leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
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?
Employer #2, in applicable
Employer #2's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer #2's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held
Dates of Employment
Reason for Leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
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?
Employer #3, in applicable
Employer #3's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer #3's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held
Dates of Employment
Reason for Leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
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?
Education Background
Did you complete High School?
Name & Location of High School
Year Graduated
Please select if you have completed any of the following
If you have marked any of the above please provide further details (name of school, year completed, etc.)
Other Qualifications
Please note any other qualifications, endorsements, certifications, etc. that you believe should be considered.
If you have a resume you would like us to review please upload it here.

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If you have any professional references you would like us to consider, please upload them here.

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If you have access to a scanner, please scan your valid driver's license and upload it here. If you don't have access to a scanner, please bring your valid driver's license to your interview for scanning.

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Consent & Certification

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 Cusumano & Sons. 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.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Cusumano & Sons, Inc. Driver Employment Application

An Equal Opportunity Employer

General Information

License Information

Driving Experience

Accident Record for the Past 3 Years

Traffic Convictions and Forfeitures for the Past 3 Years (other than parking violations)

Employment History

Education Background

Other Qualifications

Consent & Certification