Application for Employment

Step 1 of 6 - Basic Info

The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company named above.
Date*
MM slash DD slash YYYY
Position applying for*
- Contractor
- Driver
- Contractor's Driver
- Office
- Mechanic
Name*
First Middle Last
Phone Number*
Emergency Phone Number
Age
Date of Birth*
MM slash DD slash YYYY
*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.
Physical Exam Expiration Date
MM slash DD slash YYYY
Current & Three Years Previous Addresses
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Address
Street Address City State / Province / Region ZIP / Postal Code Country
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Address
Street Address City State / Province / Region ZIP / Postal Code Country
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Have you worked for this company before?*
- Yes
- No
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Reason for leaving?

Employment History
Give a Complete Record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past ten years.
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Position Held
Reason For Leaving
Supervisor's Name
First Last
Rate of Pay Last Employer
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requiremen1 of 49 CFR Part 40?
- Yes
- No
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Position Held
Reason For Leaving
Supervisor's Name
First Last
Rate of Pay Last Employer
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requiremen1 of 49 CFR Part 40?
- Yes
- No
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Position Held
Reason For Leaving
Supervisor's Name
First Last
Rate of Pay Last Employer
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requiremen1 of 49 CFR Part 40?
- Yes
- No
*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (I) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or ( 3) is of any size, used to transport hazardous materials in a quantity requiring placarding.

Driving Experience
Class of Equipment - Straight Truck
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Approximate Number of Miles (Total)
Class of Equipment - Tractor and Semi-Trailer
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Approximate Number of Miles (Total)
Class of Equipment - Tractor - Two Trailers
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Approximate Number of Miles (Total)
Class of Equipment - Tractor - Three Trailers (Triples)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Approximate Number of Miles (Total)
Class of Equipment - Other
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Approximate Number of Miles (Total)
List states operated in, for the last five years
List special courses/training completed (PTD/DDC, HazMat, etc.)
List any Safe Driving Awards you hold and from whom
Accident record for the past three years
Date of Accident
MM slash DD slash YYYY
Nature of Accident

(head on, rear end, upset, etc.)
Location of Accident
Number of People Injured
Number of Fatalities
Date of Accident
MM slash DD slash YYYY
Nature of Accident

(head on, rear end, upset, etc.)
Location of Accident
Number of People Injured
Number of Fatalities
Date of Accident
MM slash DD slash YYYY
Nature of Accident

(head on, rear end, upset, etc.)
Location of Accident
Number of Fatalities
Number of People Injured
Traffic Convictions and Forfeitures for the last three years (other than parking violations)
Date
MM slash DD slash YYYY
Location
Charge
Penalty
Date
MM slash DD slash YYYY
Location
Charge
Penalty
Date
MM slash DD slash YYYY
Location
Charge
Penalty
Driver's License (list each driver's license held in the past three years)
State
License #
Type
Endorsements
Expiration Date
MM slash DD slash YYYY
State
License #
Type
Endorsements
Expiration Date
MM slash DD slash YYYY
State
License #
Type
Endorsements
Expiration Date
MM slash DD slash YYYY
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
- Yes
- No
B. Has any license, permit or privilege ever been suspended or revoked?*
- Yes
- No
C. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?*
- Yes
- No
D. Have you ever been convicted of a felony?*
- Yes
- No
If the answers to A,B,C, or D is "YES", give details

Personal References
List three persons for references, other than family members, who have knowledge of your safety habits.
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*

To be read and signed by applicant

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty

It is agreed and understood that motor carrier or his agents may investigate the applicant's background to ascertain any and all information of certain applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from liability of any damages on account of his furnishing such information

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information to complete such examinations as may be required to complete my application.

It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

This certifies 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.
Name*
First Last
Date*
MM slash DD slash YYYY

Call us today, we would love to have you join our trucking family!
800-777-1753 ext. 206

Application for Employment

Step 1 of 6 - Basic Info

Current & Three Years Previous Addresses

Education History

Employment History

Driving Experience

Accident record for the past three years

Traffic Convictions and Forfeitures for the last three years (other than parking violations)

Driver's License (list each driver's license held in the past three years)

Personal References

To be read and signed by applicant