Truck Driver Employment Application

Your Name

Address

City

State

ZIP Code

Date of Birth

Hire Date

Telephone Number

Email Address

Previous Three Years Residency - Street Address 1

Previous Three Years Residency - City 1

Previous Three Years Residency - State 1

Previous Three Years Residency - ZIP Code 1

Previous Three Years Residency - Street Address 2

Previous Three Years Residency - City 2

Previous Three Years Residency - State 2

Previous Three Years Residency - ZIP Code 2

Previous Three Years Residency - Street Address 3

Previous Three Years Residency - City 3

Previous Three Years Residency - State 3

Previous Three Years Residency - ZIP Code 3



Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one
driver's license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.

License State

License No.

License Type

License Expiry Date

Equipment Class

Equipment Type

Equipment From

Equipment To

Approx. No. of Miles

Accident Record Dates and Nature of Accidents
Dates and Nature of Accidents
Traffic Convictions Date, Violation, State, Penalty
Date, Violation, State, Penalty
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
YesNo
B. Has any license, permit, or privilege ever been suspended or revoked?
YesNo
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years {total of ten years employment record)
Must list the complete mailing address: street number and name, city, state and zip code
Employment Record Last Employer: Name, Address, Phone, Position Held, From-To, Salary, Reasons for Leaving
Last Employer: Name, Address, Phone, Position Held, From-To, Salary, Reasons for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
YesNo
Was the previous job position designated as a safety-sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
YesNo
TO BE READ AND SIGNED BY APPLICANT
"I authorize you to make investigations and inquiries to my personal, employment, financial or medical history."

TO BE READ AND SIGNED BY APPLICANT
I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history. and other
related matiers as may he necessary in arriving at an employment decision, (Generally, inquiries regarding medical history will
be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health
care providers and ather persons from all liability in responding to inquiries and releasing information in connection with my
application.
In the event of employment, I understand that false or misleading information given in: my application or interview(s) may result in
discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
*I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, tor the purpose of investigating my safaty performance history as required by 49 CFR 394.23(¢) and (e}.
I understand that I have the right to:
» Review information provided by current/previous employers,
« Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information
to the prospective employer, and
* Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the
accuracy of the information.”

DATE

APPLICANT'S SIGNATURE
This certifies that I completed this application, and that ell entries on it ond information in it afe true and complete to the best cf my
Knowledge.