Personal Information:
Application Date:
Last Name:
First Name:
Middle Initial:
SS#
Position Applied For:
Address:
City::
State:
Zip
List your addresses of residency for the
past 3 years:
Current Address Street:
Current Address City:
Current Address Zip:
Current Address Phone:
Length of time at current residence:
Previous Address 1
Previous Address Street:
Previous Address City:
Previous Address Zip:
Length of time at this residence
Previous Address 2
Previous Address Street
Previous Address City
Previous Address Zip:
Length of time at this residence
Previous Address 3
Previous Address Street:
Previous Address City:
Previous Address Zip:
Length of time at this residence:
Do
you have the legal right to work in the
United States?
Can you provide proof of age?
Have you ever worked for this company
before?
Yes
No
If
yes, where?
If
yes, start date?
If
yes, end date?
If
yes, pay rate?
If
yes, position?
If
yes, reason for leaving?
Are you currently employed?
Yes
No
If
no, how long since last employment?
Who referred you?
Rate of pay expected:
Have you ever been bonded? (Answer only if
job requirement)
Name of bonding company:
Have you ever been convicted of a felony?:
If
yes, explain:
Is
there any reason you might be unable to
perform the functions of the job for which
you have applied?:
Yes
No
If
yes, explain if you wish::
YOUR FORMER EMPLOYERS
All driver applicants to drive in interstate
commerce must provide the following
information on all employers during the
preceding 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. (NOTE: List
employers in reverse order starting with the
most recent. Add another sheet as
necessary.)
*Includes vehicles having a GVWR of 26,001
lbs. or more, vehicles designed to transport
15 or more passengers, or any size vehicle
used to transport hazardous materials in a
quantity requiring placarding.
Name of Last Employer:
Address:
City:
State:
Zip:
Starting Date:
Ending Date:
Job Title:
Weekly Starting Salary:
May We Contact Your Supervisor:
Yes
No
Name of Supervisor:
Title:
Phone:
Description of Work:
Reason for Leaving:
Did you drive a vehicle requiring a CDL?:
Yes
No
Name of Last Employer:
Address:
City:
State:
Zip:
Starting Date:
Ending Date:
Job Title:
Weekly Starting Salary:
May We Contact Your Supervisor:
Yes
No
Name of Supervisor:
Title:
Phone:
Description of Work:
Reason for Leaving:
Did you drive a vehicle requiring a CDL?:
Yes
No
Name of Last Employer:
Address:
City:
State:
Zip:
Starting Date:
Ending Date:
Job Title:
Weekly Starting Salary:
May We Contact Your Supervisor:
Yes
No
Name of Supervisor:
Title:
Phone:
Description of Work:
Reason for Leaving:
Did you drive a vehicle requiring a CDL?:
Yes
No
Name of Last Employer:
Address:
City:
State:
Zip:
Starting Date:
Ending Date:
Job Title:
Weekly Starting Salary:
May We Contact Your Supervisor:
Yes
No
Name of Supervisor:
Title:
Phone:
Description of Work:
Reason for Leaving:
Did you drive a vehicle requiring a CDL?:
Yes
No
Name of Last Employer:
Address:
City:
State:
Zip:
Starting Date:
Ending Date:
Job Title:
Weekly Starting Salary:
May We Contact Your Supervisor:
Yes
No
Name of Supervisor:
Title:
Phone:
Description of Work:
Reason for Leaving:
Did you drive a vehicle requiring a CDL?:
Yes
No
Name of Last Employer:
Address:
City:
State:
Zip:
Starting Date:
Ending Date:
Job Title:
Weekly Starting Salary:
May We Contact Your Supervisor:
Yes
No
Name of Supervisor:
Title:
Phone:
Description of Work:
Reason for Leaving:
Did you drive a vehicle requiring a CDL?:
Yes
No
ACCIDENT RECORDS
Accident records for past 3 years or more
(attach sheet if more space is needed) If
none, write NONE.
Date, Nature of Accident(Head-On,Rear-End,
Upset, Etc), Fatalities, Injuries of Last
Accident :
Date, Nature of Accident(Head-On,Rear-End,
Upset, Etc), Fatalities, Injuries of Last
Accident :
Date, Nature of Accident(Head-On,Rear-End,
Upset, Etc), Fatalities, Injuries of Last
Accident :
TRAFFIC CONVICTIONS
And forfeitures for the past 3 years (other
than parking violations) If none, write
NONE.
Location, Date, Charge, & Penalty of Last
Traffic Conviction:
Location, Date, Charge, & Penalty of Last
Traffic Conviction:
Location, Date, Charge, & Penalty of Last
Traffic Conviction:
EDUCATION
Highest Level Completed:
High School Grade Completed:
College Level Completed:
Last School Attended
(name & city)
DRIVERS LICENSES
State, License No, Type, Expiration Date:
State, License No, Type, Expiration Date:
State, License No, Type, Expiration Date:
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
If
the answer to A or B is yes, give details:
DRIVING EXPERIENCE (If none, write "NONE")
Class of Equipment:
Straight Truck (Type of Equipment, From/To
Date, Approx Number of Total Miles):
Tractor and Semi-Trailer (Type of Equipment,
From/To Date, Approx Number of Total Miles):
Tractor-Two Trailers (Type of Equipment,
From/To Date, Approx Number of Total Miles):
Motorcoach - Schoolbus (Type of Equipment,
From/To Date, Approx Number of Total Miles):
Other (Type of Equipment, From/To Date,
Approx Number of Total Miles):
List states operated in for last five years:
Show special courses or training that will
help you as a driver:
Which safe driving award do you hold and
from whom?:
EXPERIENCES AND QUALIFICATIONS - OTHER
Show any trucking, transportation, or other
experience that may help in your work for
this company: Date, Approx Number of Total
Miles):
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):
To be read and signed by applicant
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.
I authorize you to make such investigation
and inquiries of my personal, employment,
financial, or medical history and other
related matters 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.
DATE:
SIGNATURE (ENTER NAME) :