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Truck Driver Application Form

CONTACT INFORMATION

Applicant Name

Phone Number

Email Address for contact (optional)

List your previous addresses of residency for the past 3 years

Current Address (Street, City, State, ZIP)

How long?

Previous Address (Street, City, State, ZIP)

How long?

Previous Address (Street, City, State, ZIP)

How long?

Previous Address (Street, City, State, ZIP)

How long?

Date of Birth

If so, where?

Dates Previously Employeed (From - To)

Previous Rate of Pay

Previous Position

Reason for leaving

If not, how long since leaving last employment?

Who referred you?

Rate of pay expected

Name of bonding company

If yes, please explain

If there is any reason you might be unable to perform the functions of the job for which you have applied (as described in the attached job description)?If yes, please explain

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 of those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting wi

( * 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.)

Employer Name

Date Employed (From - To)

Position Held

Address

City

State

Zip

Salary

Contact Person

Contact #

Reason for leaving

Employer Name

Date Employed (From - To)

Position Held

Address

City

State

Zip

Salary

Contact Person

Contact #

Reason for leaving

Employer Name

Date Employed (From - To)

Position Held

Address

City

State

Zip

Salary

Contact Person

Contact #

Reason for leaving

Employer Name

Date Employed (From - To)

Position Held

Address

City

State

Zip

Salary

Contact Person

Contact #

Reason for leaving

Employer Name

Date Employed (From - To)

Position Held

Address

City

State

Zip

Salary

Contact Person

Contact #

Reason for leaving

ACCIDENT RECORD

For past 3 years or more. If none, check NONE here

Last Accident Date

Nature of accident

Next Previous Accident Date

Nature of accident

Next Previous Accident Date

Nature of accident

Traffic Convictions and Forfeitures for the last 3 years

If none, check NONE here

Traffic Location

Date

Charge

Penalty

Traffic Location

Date

Charge

Penalty

Traffic Location

Date

Charge

Penalty

Experience and Qualifications - Driver

State

License No

Endorsements

Type

Expiration Date

State

License No

Endorsements

Type

Expiration Date

Driving Experience

Dates (From - To)

Approx total number of miles

Dates (From - To)

Approx total number of miles

Dates (From - To)

Approx total number of miles

Dates (From - To)

Approx total number of miles

Dates (From - To)

Approx total number of miles

Class: Other

List states operated in for the last 5 years

Any special courses or training that will help you as a driver?

What safe driving awards do you hold and from whom?

EXPERIENCE AND QUALIFICATIONS - OTHER

Show any trucking, transportation or other experience that may help you in your work for this company

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)

EDUCATION

Last School Attended (Name, City, State)

TO BE READ AND INITIALED BY APPLICANT

I authorize you to make such investigations 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, enquiries 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.

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 th einformation corrected by previous employers and for those 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.

Initials

Date