Driver Application Form

Name*
Date of Birth*

MonthDayYear
Phone number*
Email*
example@example.com
Can you provide proof of age?*

YesNo
In which positions are you interested?*

Short-haul Regional Flatbed Driver (Seasonal)Long-haul O.T.R. (year-round)Either / Both

EMPLOYMENT RECORD
Note: Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall provide 10 years of information on those employers for whom the applicant operated such vehicle. All other applicants must provide 3 years of the following employment information.

If necessary, additional employment details will be requested at a later date.

*Includes vehicles that have a GVWR of 26,001 lbs or more, vehicles designed to transport 16 or more passengers (including driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
Are you currently employed?*

YesNo
If not, how long since your last employment?
Current / Most Recent Employer
Company Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*
End Date*
Position Held*
Reason for Leaving*
Contact Person
Phone Number
Were you subject to the FMCSRs** while employed?*

YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol requirement of 49 CFT part 40?*

YesNo
Do you need to add additional employment history to fulfill 10 years of commercial driving experience or 3 years of other employment experience?*

YesNo

Accident Record
During the past 3 years, have you been involved in any personal or commercial vehicle collisions or accidents?*

YesNo
If yes to the above question, please provide details:

Traffic Convictions and Forfeitures
During the past 3 years, have you been convicted of any traffic violations or been required to forfeit your driver's license for any period of time?*

YesNo

Driving Qualifications
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*

YesNo
If yes to the above question, please provide details:
Has any license, permit, or privilege to operate a motor vehicle ever been suspended or revoked?*

YesNo
If yes to the above question, please provide details:

CURRENT LICENSE / PERMIT
Issuing State*
License / Permit Number*
License / Permit Type*
Expiration Date

MonthDayYear
Section 383.21 of the FMCSR states, "No person who operates a commercial vehicle shall at any time have more than one driver's license." If you certify that you do not have more than one motor vehicle license, the information for which is listed above, please type your first and last name below.*

Education
Highest Level of Schooling Completed*

Middle SchoolHigh SchoolCollegeGraduate School
Last School Attended*

Authentication
I certify that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Please accept*

I AGREE

Current Residence