Position(s) Applied for Email First name Last name Middle name Social Security No. List your addresses of residency for the past 3 years. Current Adress Street City Phone State Zip Code How long Previous Adresses Address 1 Street City State Zip Code How long Address 2 Street City State Zip Code How long Address 3 Street City State Zip Code How long Do you have the legal right to work in the United States? Date of Birth Can you provide proof of age? Have you worked for this company before ? Where ? Dates: From To Rate of Pay Position Reason for leaving Are you now employed? If not, how long since leaving last employment? Who referred you ? Rate of pay expected ? Have you ever been bonded? Name of bonding company Have you ever been convicted of a felony? If yes, please explain fully in details. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered. Is there any reason you might be unable to perform the functions of the job for which you have applied? If yes, explain if you wish. EMPLOYMENT HISTORY Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce must also provide an 10 years’ information on those employers for whom the applicant operated such vehicle. Employers information. Employer 1 Employer's full name Employer's address Employer's city Employer's state Employer's ZIP Employer's Phone Employer's contact person 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 testing requirements of 49 CFR part 40? yesno Dates: From To Position held Salary/Wage Reason for leaving Employer 2 Employer's full name Employer's address Employer's city Employer's state Employer's ZIP Employer's Phone Employer's contact person 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 testing requirements of 49 CFR part 40? yesno Dates: From To Position held Salary/Wage Reason for leaving Employer 3 Employer's full name Employer's address Employer's city Employer's state Employer's ZIP Employer's Phone Employer's contact person 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 testing requirements of 49 CFR part 40? yesno Dates: From To Position held Salary/Wage Reason for leaving Employer 4 Employer's full name Employer's address Employer's city Employer's state Employer's ZIP Employer's Phone Employer's contact person 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 testing requirements of 49 CFR part 40? yesno Dates: From To Position held Salary/Wage Reason for leaving Employer 5 Employer's full name Employer's address Employer's city Employer's state Employer's ZIP Employer's Phone Employer's contact person 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 testing requirements of 49 CFR part 40? yesno Dates: From To Position held Salary/Wage Reason for leaving Employer 6 Employer's full name Employer's address Employer's city Employer's state Employer's ZIP Employer's Phone Employer's contact person 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 testing requirements of 49 CFR part 40? yesno Dates: From To Position held Salary/Wage Reason for leaving ACCIDENT RECORD FOR PAST 3 YEARS OR MORE LAST ACCIDENT Date Nature of Accident Fatalities Injuries Hazardous material spill Next previous Date Nature of Accident Fatalities Injuries Hazardous material spill Next previous Date Nature of Accident Fatalities Injuries Hazardous material spill TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) LAST CONVICTION Location Date Charge Penalty Next previous Location Date Charge Penalty Next previous Location Date Charge Penalty EXPERIENCE AND QUALIFICATIONS. List all driver licenses or permits held in the past 3 years Driver licenses & Endorsements License 1 State License No. Type Expiration date Endorsement License 2 State License No. Type Expiration date Endorsement License 3 State License No. Type Expiration date Endorsement 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 If the answer to either A or B is yes, provide details DRIVING EXPERIENCE Straight Truck Experience in driving yesno Circle type of equipment VanTankFlatDumpRefer Dates: From To Approx No. of miles Tractor and semi-trailer Experience in driving yesno Circle type of equipment VanTankFlatDumpRefer Dates: From To Approx No. of miles Tractor - two trailers Experience in driving yesno Circle type of equipment VanTankFlatDumpRefer Dates: From To Approx No. of miles Tractor - three trailers Experience in driving yesno Circle type of equipment VanTankFlatDumpRefer Dates: From To Approx No. of miles Motorcoach - School Bus (more than 8 passengers) Experience in driving yesno Dates: From To Approx No. of miles Motorcoach - School Bus (more than 15 passengers) Experience in driving yesno Dates: From To Approx No. of miles Other Equipment Class Dates: From To Approx No. of miles List states operated in last 5 years Show special courses or training that will help you as a driver Which sae driving awards do you hold and from whom? OTHER EXPERIENCE Show any trucking, transportation or other experience that may help in your work for this company List courses and training other than shown elsewhere in this application List special equipment or technical materials you can work with (other than those already shown) Education Highest grade completed 12345678 High School 1234 College 1234 Name of the last school attended City, State Your signature *