CT Application

COSHOCTON TRUCKING INC.

Rolling Towards the Future...
DRIVER APPLICATION

Please give complete answers to ALL questions - Incomplete answers will only slow, or stall the application and our goal is to get you hired quickly.
Position Applying For
General Information
Full Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Email
example@example.com
Have you lived at this address 3 years or more?

Yes No

If no, please list previous addresses below

Street

City

State/Zip

How Long?

Previous Address

Social Security Number *
Date of Birth *

Month Day Year
Phone Number *

Area Code Phone Number
E-mail *
Have you ever been known by any other name?

Yes No
Please list name
Explain ie; maiden name, name change
If hired, can you furnish proof you are eligible to work in the U.S.? *

Yes No
Are you at least 23 years of age or older? *

Yes No
License Information
Do you hold a current CDL license?

Yes No
CDL Issue Date

Month Day Year
Date
Have you held a VALID US license for the past 36 months? *

Yes No
License Class *
License Number *
State of Issue *
License expiration date *

Month Day Year
Expiration date of DOT physical card

Month Day Year
CDL Endorsements *

None Tanker Doubles/Triples Hazmat X Endorsement TWIC
Hazmat expiration date

Month Day Year
TWIC expiration date

Month Day Year
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? *

Yes No
Branch of service
Please list Dates of enlistment
Enlist date - Discharge date
Did you receive an honorable discharge?

Yes No Other
Do you have, or can you obtain your DD214?

Yes No I can obtain one
Have you been to truck driving school?

Yes No
School information

School Name

Dates of attendance

City State / Province

GPA if available Country
School phone number

Area Code Phone Number
Did you graduate?

Yes No
EMPLOYMENT HISTORY
Work History for Past 10 Years:

Please list current, or most recent employment first.
Employer #1
Start date *

Month Day Year
Ending date *

Month Day Year
City, State *
Employer phone *

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

Yes No
May we contact this employer at this time? *

Yes No
Was this a driving position?

Yes No
Type of truck
Type of trailer
Trailer length
Number of states driven
NEXT EMPLOYER
Employer #2
Start date

Month Day Year
Ending date

Month Day Year
City, State
Position Held
Reason for leaving
Employer phone

Area Code Phone Number
Was this a driving position?

Yes No
Type of truck
Type of trailer
Trailer length
Number of states driven
NEXT EMPLOYER
Employer #3
Starting date

Month Day Year
Ending date

Month Day Year
City, State
Position Held
Employer phone

Area Code Phone Number
Reason for leaving
Was this a driving position

Yes No
Type of truck driven
Type of trailer
Trailer length
Number of states driven
Start Date

Month Day Year
End Date

Month Day Year
NEXT EMPLOYER
Employer #4
City and State
Position
Employer Phone

Area Code Phone Number
Reason for leaving
Was this a driving position

Yes No
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.
Additional Information
Have you had any moving violations in the last 5 years? *

Yes No
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? *

Yes No
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? *

Yes No
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? *

Yes No
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? *

Yes No
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
Have you ever been convicted of a misdemeanor? *

Yes No
If yes, please list date and nature of offense, city, county and state. also jail time, probation, or fines
Please list EVERYTHING asked for
Additional Information
References: Please list name, address, phone and years known.
Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
Number of years known
Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
Number of years known
Emergency Contact Information
Full Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Relationship to you *
Phone Number *

Area Code Phone Number
HIGH SCHOOL
Name & City/State of High School
Did you graduate?

Yes No
By signing I agree I have read the above statements
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COSHOCTON TRUCKING INC.

General Information

License Information

EMPLOYMENT HISTORY

Work History for Past 10 Years:

Additional Information

Additional Information

References: Please list name, address, phone and years known.

Emergency Contact Information