Personal Information

*Name: (Last, First, Middle)

*Phone Number:

*Email:

*Present Address:

*City:

*State:

*Zip:

Are you 18 years or older?

Yes No

Date Available to Start:

Other Addresses in Last 3 Years

Previous Address:

City:

State:

Zip:

Previous Address:

City:

State:

Zip:

Previous Address:

City:

State:

Zip:

Desired Employment

*Position:

Salary Desired:

Have you applied to this company before?

Yes No

Previous Employment

Any gaps in employment must be explained.
Any applicant wishing to be employed in a driving function (or possessing a Commercial Drivers License class A, B, or C) must provide the following information on all employers during the preceding three years.

Current or Last Employer

Name:

Phone Number:

Address:

City:

State:

Zip:

Position:

Name of Supervisor:

Description of Work Performed:

Reason for Leaving:

Were you subject to the FMCSRs while employed? Yes No

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? Yes No

Previous Employer

Name:

Phone Number:

Address:

City:

State:

Zip:

Position:

Name of Supervisor:

Description of Work Performed:

Reason for Leaving:

Were you subject to the FMCSRs while employed? Yes No

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? Yes No

Previous Employer

Name:

Phone Number:

Address:

City:

State:

Zip:

Position:

Name of Supervisor:

Description of Work Performed:

Reason for Leaving:

Were you subject to the FMCSRs while employed? Yes No

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? Yes No

Account for Gaps in Employment:

Experience and Qualifications

Driving Experience

What type of Driver’s License do you have?

State:

License Number:

Expiration:

Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No

Has any license, permit, or privilege ever been suspended or revoked? Yes No

How many years of driving experience do you have, and in what type of vehicle? List experience in each type.

Equipment Operating Experience

Please list (one per line) equipment you can operate and number of years experience.

Accident History

If you've had an accident within the last three years check here:

Date (mo/yr)

Nature of Accident (head-on, rear end, etc.)

Number of Fatalities

Number of Injuries

Hazardous Materials Spill?

Traffic Convictions History

If you've had any traffic convictions and/or Forfeitures within last three years check here:

Date Convicted (mo/yr)

Violation (other than parking)

State of Violation

Penalty (Forfeited bond, points)

General Questions

Who referred you to this company?

Are you a citizen of the United States? Yes No

Are you eligible to work in the United States? (Proof required) Yes No

Are you available for weekend work including Sunday? Yes No

Have you ever needed extended time away from work? Yes No

Have you ever been convicted of a felony? Yes No

Is an accommodation necessary to perform the functions of this position? Yes No

TO BE READ AND AGREED ON BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment or financial history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools 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 also understand that I am required to abide by all rules and regulations of the Company. “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 that I have the right to:

-Review information provided by current/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.”

*Check here to agree

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