Truck Driver Application Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How long have you lived at this address * Date of Birth * MM DD YYYY Social Security Number Phone * (###) ### #### Email * Date Available for Hire MM DD YYYY Previous Three Years of Residency Address Address 1 Address 2 City State/Province Zip/Postal Code Country Address Address 1 Address 2 City State/Province Zip/Postal Code Country Address Address 1 Address 2 City State/Province Zip/Postal Code Country License Information 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. State * License No. * Type * Expiration Date * MM DD YYYY Driving Experience Straight Truck Type of Equipment Van Tank Flat Other Dates - From/To Approx. Number of Miles (Total) Tractor and Semi-Trailer Type of Equipment Van Tank Flat Etc... Dates- From/To Approx. Number of Miles (Total) Tractor - Two Trailers Type of Equipment Van Tank Flat Etc... Dates - To/From Approx. Number of Miles (Total) Accident Record for the Past 3 Years of More Date MM DD YYYY Nature of Accident Number of Fatalities Number of Injuries Chemical Spills Yes No Date 2 MM DD YYYY Nature of Accident Number of Fatalities Number of Injuries Chimcal Spills Yes No Date 3 MM DD YYYY Nature of Accident Number of Fatalities Numberof Injuries Chemical Spills Yes No Traffic Convictions and Forfeitures For the Past 3 Years (other than Parking Violation) Date Convicted MM DD YYYY Violation State of Violation Location Penalty (forfeited bond, collateral and/or points) Date Convicted MM DD YYYY Violation State of Violation Location Penalty (forfeited bond, collateral and/or points) Date Convicted MM DD YYYY Violation State of Violation Location Penalty (forfeited bond, collateral and/or points) Have you ever been denied a license, permit or privilege to operate a motor vehicle Yes No If yes, explain Has any license, permit or privelage ever been suspended or revoked? Yes No If yes, explain Employment Record 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. Last Employer: Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Position Held Start Date MM DD YYYY End Date MM DD YYYY Salary Reason for Leaving Any Gaps in Employment and/or Unemployment Must Be Explained. Include Dates (Month/Year) Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer Yes No Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirement as required by 49 CFR Part 40? Yes No Second Last Employer: Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Position Held Start Date MM DD YYYY End Date MM DD YYYY Salary Reason for Leaving Any Gaps in Employment and/or Unemployment Must Be Explained. Include Dates (Month/Year) Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer Yes No Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirement as required by 49 CFR Part 40? Yes No Third Last Employer: Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Position Held Date From MM DD YYYY Date To MM DD YYYY Salary Any Gaps in Employment and/or Unemployment Must Be Explained. Include Dates (Month/Year) Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer Yes No Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirement as required by 49 CFR Part 40? Yes No To Be Read and Agreed To By Applicant I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be 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 other 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 for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that have the right to: - Review information provided by current/previous employers: - Have errors in the information corrected by previous employers and for those previous to re-send the corrected information to the prospective employer: and - Have a rebuttal statement attached to the alleged erroneous information, in the previous employer(s) and I cannot agree on the accuracy of the information" This certifies that I completed this application, and that entries on it and information in it are true and complete to the best of my knowledge * Yes Date * MM DD YYYY Name * First Name Last Name Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations. * Yes Date * MM DD YYYY Name * First Name Last Name Thank you!
