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 NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

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

YesNo

If no, please list previous addresses below

Rows	Street	City	State/Zip	How Long?
Previous Address
Previous Address
Previous Address

Social Security Number*
Date of Birth*

MonthDayYear
Phone Number*

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

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
Are you at least 23 years of age or older?*

YesNo
License Information
Do you hold a current CDL license?

YesNo
CDL Issue Date

MonthDayYear
Date
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
Hazmat expiration date

MonthDayYear
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
Branch of service
Please list Dates of enlistment
Enlist date - Discharge date
Did you receive an honorable discharge?

YesNoOther
Do you have, or can you obtain your DD214?

YesNoI can obtain one
Have you been to truck driving school?

YesNo
School information

School Name

Dates of attendance

CityState / Province

GPA if availableCountry
School phone number

Area CodePhone Number
Did you graduate?

YesNo
EMPLOYMENT HISTORY
Work History for Past 10 Years:

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

MonthDayYear
Ending date*

MonthDayYear
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
Employer #2
Start date

MonthDayYear
Ending date

MonthDayYear
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
Employer #3
Starting date

MonthDayYear
Ending date

MonthDayYear
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
NEXT EMPLOYER
Employer #4
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.
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
Have you ever been convicted of a misdemeanor?*

YesNo
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

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Number of years known
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Number of years known
Emergency Contact Information
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Relationship to you*
Phone Number*

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

YesNo
By signing I agree I have read the above statements
Should be Empty:

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