Career

Company Name(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Position Applying for:(Required)

Date of Application:(Required)

Name(Required)

First Middle Last

Social Security No.:(Required)

Current Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Birth Date(Required)

Previous Addresses: (3 Years)(Required)

Street Address City State / Province / Region ZIP / Postal Code

Date From(Required)

Date To(Required)

Street Address City State / Province / Region ZIP / Postal Code

Date From(Required)

Date To(Required)

Street Address City State / Province / Region ZIP / Postal Code

Date From(Required)

Date To(Required)

Use backside of sheet for additional addresses

Driver's License information: List all licenses held within the previous 3 years

License number(Required)

Class(Required)

State(Required)

Exp. Date(Required)

License number(Required)

Class(Required)

State(Required)

Exp. Date(Required)

License number(Required)

Class(Required)

State(Required)

Exp. Date(Required)

Have you ever had any driver's license denied, suspended, revoked, or canceled by any state agency?(Required)

Yes

No

YES If yes, give state of issuance and explanation of the circumstances(Required)

Use backside of sheet if additional space is needed

Types Of Equipment(Required)

Date To(Required)

Date From(Required)

Approx. mileage driven (total)(Required)

Types Of Equipment(Required)

Date To(Required)

Date From(Required)

Approx. mileage driven (total)(Required)

Types Of Equipment(Required)

Date To(Required)

Date From(Required)

Approx. mileage driven (total)(Required)

Employment History

List all employment for the previous 3 years, all driving jobs for the previous 10 years, including any gaps between employers.

Employer(Required)

Supervisor(Required)

Period of Employment From(Required)

Period of Employment To(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Title and Duties(Required)

Reason for Leaving(Required)

Were you subject to the Federal Motor Carrier Safety Regulations during this period?(Required)

Yes

No

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?(Required)

Yes

No

Employer

Supervisor

Period of Employment From

Period of Employment To

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Title and Duties

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes

No

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes

No

Employer

Supervisor

Period of Employment From

Period of Employment To

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Title and Duties

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes

No

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes

No

Employer

Supervisor

Period of Employment From

Period of Employment To

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Title and Duties

Reason for Leaving

Employer

Supervisor

Period of Employment From

Period of Employment To

Address

Street Address City State / Province / Region ZIP / Postal Code

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes

No

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes

No

Employer

Supervisor

Period of Employment To

Period of Employment From

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Title and Duties

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes

No

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes

No

(Use additional sheet if needed)

For Driver applicants of commercial motor vehicles that require a Commercial Driver's License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).

As a perspective driver employee, you will have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective employer; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer provided investigative information, must submit a written request to the prospective employer, which may be done at any time, including when applying or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five (5) business day deadline will begin when the perspective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.

Certification

"I certify 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."

Applicant's Signature(Required)

Date Signed(Required)

ANNUAL VIOLATION AND REVIEW RECORD

Driver's Name:(Required)

(PLEASE PRINT OR TYPE)

I. CERTIFICATION OF VIOLATIONS (Part 391.27)

I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months.

Date(Required)

Offense(Required)

Location(Required)

Type Vehicle Operated(Required)

Date

Offense

Location

Type Vehicle Operated

Date

Offense

Location

Type Vehicle Operated

Date

Offense

Location

Type Vehicle Operated

Date

Offense

Location

Type Vehicle Operated

Date

Offense

Location

Type Vehicle Operated

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months.

DATE OF CERTIFICATION(Required)

(DRIVER'S SIGNATURE)(Required)

(MOTOR CARRIER'S NAME)(Required)

(MOTOR CARRIER'S ADDRESS)(Required)

(REVIEWED BY SIGNATURE)(Required)

(TITLE)(Required)

II. ANNUAL REVIEW OF DRIVING RECORD (Part 391.25)

In accordance with Section 391.25, Motor Carrier Safety Regulations, all information pertinent to the above driver's safety of operations, including the list of violations furnished by him in accordance with Section 391.27, has been reviewed for the past 12 months. I considered any evidence that the driver has violated applicable provisions of the FMCSR's and the Hazardous Materials Regulations. I considered the driver's accident record and any evidence that he/she has violated laws governing the operations of motor vehicles and gave great weight to violations such as: speeding, reckless driving, and operations while under the influence of alcohol or drugs, that indicate that the driver has exhibited a disregard for the safety of the public. Having done the above, I find that

Untitled(Required)

The driver meets the minimum requirements for safe driving, or

The driver is disqualified to drive a commercial motor vehicle pursuant to Part 391.15

(MOTOR CARRIER'S NAME)(Required)

(MOTOR CARRIER'S ADDRESS)(Required)

Signature(Required)

Title(Required)

Date(Required)

General Freight

Over-sized loads

Food and beverage

Building materials

Employment Application

Use backside of sheet for additional addresses

Driver's License information: List all licenses held within the previous 3 years

Use backside of sheet if additional space is needed

List all traffic violations convictions for the previous 3 years ( Write NONE, if NONE )

List all accidents for the previous 3 years ( Write NONE, if NONE )

Employment History

(Use additional sheet if needed)

Certification

ANNUAL VIOLATION AND REVIEW RECORD

II. ANNUAL REVIEW OF DRIVING RECORD (Part 391.25)

Links

Contact Info