Driver's Application for Employment

Applicant Name:
Company:
Address:
City:
State:
Zip:
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

TO BE READ AND SIGNED BY APPLICANT 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 I have the right to: Review information provided by 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.

Signature           



APPLICANT TO COMPLETE

Previous Address: Please list your last 3 addresses





Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding 3 years. List complete mailing address, street number, city, state, and zip code.
Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.

Employer

Name of present or last employer Start Date  
Address End Date  
City, State Zip Position Held  
Reason for leaving Salary / Wage
Contact Person Phone Number  
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG    

Employer

Name of present or last employer Start Date  
Address End Date  
City, State Zip Position Held  
Reason for leaving Salary / Wage
Contact Person Phone Number  
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG    

Employer

Name of present or last employer Start Date  
Address End Date  
City, State Zip Position Held  
Reason for leaving Salary / Wage
Contact Person Phone Number  
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG    

Employer

Name of present or last employer Start Date  
Address End Date  
City, State Zip Position Held  
Reason for leaving Salary / Wage
Contact Person Phone Number  
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG    

Employer

Name of present or last employer Start Date  
Address End Date  
City, State Zip Position Held  
Reason for leaving Salary / Wage
Contact Person Phone Number  
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG    

Employer

Name of present or last employer Start Date  
Address End Date  
City, State Zip Position Held  
Reason for leaving Salary / Wage
Contact Person Phone Number  
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG    


* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

† The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Accident Record

FOR PAST 3 YEARS OR MORE IF NONE, WRITE NONE

Traffic Convictions

AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

Experience and Qualifications -Driver

Driving Experience