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Listing Position
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Listing ID
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Listing Contact
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Listing Company
APPLICANT INFORMATION
Name
First Middle Last
Social Security Number
Date of Birth
Primary Phone
Secondary Phone
Email Address
Preferred Method of Contact
Preferred Time
Do you have legal right to work in the United States?
- Yes
- No
PREVIOUS THREE YEARS OF RESIDENCY
Current Address
Street Address City State ZIP Code
Number of Years at Current Address
Previous Address
Street Address City State ZIP Code
Previous Address
Street Address City State ZIP Code

LICENSE INFORMATION
No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years.
License Number
Issuing State
State
Type/Class
Endorsements
Expiration Date
PREVIOUS HELD LICENSES
License Number
Issuing State
State
Type/Class
Endorsements
Expiration Date
License Number
Issuing State
State
Type/Class
Endorsements
Expiration Date
DRIVING EXPERIENCE
Class of Equipment
Type of Equipment (Van, Tank, Flat, etc.)
Date From
Date To
Approx # of Miles (Total)
Class of Equipment
Type of Equipment (Van, Tank, Flat, etc.)
Date From
Date To
Approx # of Miles (Total)
Class of Equipment
Type of Equipment (Van, Tank, Flat, etc.)
Date From
Date To
Approx # of Miles (Total)

ACCIDENT RECORD FOR THE PAST 3 YEARS
List most recent accidents first.
Date
Nature of Accident (Head-on, rear-end, upset, etc.)
# of Fatalities
# of Injuries
Chemical Spills
Date
Nature of Accident (Head-on, rear-end, upset, etc.)
# of Fatalities
# of Injuries
Chemical Spills
Date
Nature of Accident (Head-on, rear-end, upset, etc.)
# of Fatalities
# of Injuries
Chemical Spills
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS
Do not include parking violations.
Date Convicted
Violation
State of Violation
State / Province / Region
Penalty (Forfeited bond, collateral and/or points)
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
If yes, explain:
Has any license, permit, or privilege ever been suspended or revoked?
If yes, explain:

EMPLOYMENT HISTORY
The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.
CURRENT (MOST RECENT) EMPLOYER
Employer Name
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Position Held
From (Month/Year)
To (Month/Year)
Reason for Leaving
Salary
Explain Any Gaps in Employment (Include month/year and reason)
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?
SECOND (MOST RECENT) EMPLOYER
Employer Name
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Position Held
Reason for Leaving
From (Month/Year)
To (Month/Year)
Salary
Explain Any Gaps in Employment (Include month/year and reason)
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?
THIRD (MOST RECENT) EMPLOYER
Employer Name
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Position Held
Reason for Leaving
From (Month/Year)
To (Month/Year)
Salary
Explain Any Gaps in Employment (Include month/year and reason)
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

EDUCATION
HIGH SCHOOL
High School Name
Location (City, State)
Years Attended
Graduated?
COLLEGE
College Name
Location (City, State)
Course of Study
Years Attended
Graduated?
OTHER
School Name
Location (City, State)
Course of Study
Years Attended
Graduated?
OTHER QUALIFICATIONS
Please list any other qualifications that you have and which you believe should be considered.
TO BE READ BY APPLICANT
I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior 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. 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 resend 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. This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.
Applicant Name
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Apply for Job

Apply for Apply for Job

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APPLICANT INFORMATION

PREVIOUS THREE YEARS OF RESIDENCY

LICENSE INFORMATION

PREVIOUS HELD LICENSES

DRIVING EXPERIENCE

ACCIDENT RECORD FOR THE PAST 3 YEARS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS

EMPLOYMENT HISTORY

CURRENT (MOST RECENT) EMPLOYER

SECOND (MOST RECENT) EMPLOYER

THIRD (MOST RECENT) EMPLOYER

EDUCATION

HIGH SCHOOL

COLLEGE

OTHER

OTHER QUALIFICATIONS

TO BE READ BY APPLICANT