Driver Application

Company *

Street Address *

City *

State *

Zip Code *

First Name *

Middle

Maiden Name

Last *

Street Address *

City *

State & Zip Code *

How Long *

Date of Birth *

Social Security Number *

Hire Date *

Telephone NumberPhone *

Email Address *

Previous Three Years Residency

Address

City

State & Zip Code

# Years

Address

City

State & Zip Code

# Years

Address

City

State & Zip Code

# Years

Additional Address Information (If Needed)

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 *

Date of Accident

Nature of Accident (head-on, rear-end, upset, etc.)

Number of Fatalities

Number of Injuries

Chemical SpillsYesNo

Date of Accident

Nature of Accident (head-on, rear-end, upset, etc.)

Number of Fatalities

Number of Injuries

Chemical SpillsYesNo

Date of Accident

Nature of Accident (head-on, rear-end, upset, etc.)

Number of Fatalities

Number of Injuries

Chemical SpillsYesNo

Additional Accident Information (If Needed)

Traffic Convictions and Forfeitures for the Past 3 Years (Other Than Parking Violations)

Date Convicted

Violation

State of Violation Location

Penalty (forfeited bond, collateral and/or points)

Date Convicted

Violation

State of Violation Location

Penalty (forfeited bond, collateral and/or points)

Date Convicted

Violation

State of Violation Location

Penalty (forfeited bond, collateral and/or points)

Additional Traffic Conviction Information (If Needed)

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

If yes, explain

Has any license, permit or privilege ever been suspended or revoked? *YesNo

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

Phone

Position Held

From

Salary

Reason For Leaving

Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?YesNo

Was the previous job 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

Second Last Employer: Name

Address

Phone

Position Held

From

Salary

Reason For Leaving

Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?YesNo

Was the previous job 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

Third Last Employer: Name

Address

Phone

Position Held

From

Salary

Reason For Leaving

Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?YesNo

Was the previous job 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

Additional Employment Information (If Needed)

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 manners 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 I have a 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 all entries on it and information in it are true and complete to the best of my knowledge.

Date *

Applicant's Signature *

Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

To apply as a driver, please click to download our application, or complete the application online below.

Previous Three Years Residency

License Information

Driving Experience

Straight Truck

Tractor and Semi-Trailer

Tractor - Two Trailers

Other

Accident Record for Past 3 Years or More

Traffic Convictions and Forfeitures for the Past 3 Years (Other Than Parking Violations)

Employment Record

To Be Read and Signed By Applicant