Commercial Driver Application APPLICANT INFORMATION Date * Position Applying For: * Driver Owner Operator Name * Email Address * Phone Number * Emergency Phone Number Date of Birth * (The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.) Physical Exam Expiration Date * CURRENT & PREVIOUS THREE YEARS ADDRESSES: Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal How long have you been at this address? * Add 2nd Address? * Yes No Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Move Out Date * Move In date * Add 3rd Address? Yes No Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Move In date * Move Out Date * EDUCATION HISTORY Please select the highest grade completed: * Grade school: 10Grade school: 11Grade school: 12College/Trade School: 1College/Trade School: 2College: 3College 4Post Graduate EMPLOYMENT HISTORY Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years. Employer Name * Start Date * End Date * Position Held * Address * Phone Number * Reason For Leaving * Were you subject to the FMCSRs while employed here? * 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 Add 2nd Employer * Yes No Employer Name * Start Date * End Date * Position Held * Address * Phone Number * Reason For Leaving * Were you subject to the FMCSRs while employed here? * 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 Add 3rd Employer * Yes No Employer Name * Start Date * End Date * Position Held * Address * Phone Number * Reason For Leaving * Were you subject to the FMCSRs while employed here? * 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 Add 4th Employer * Yes No Employer Name * Start Date * End Date * Position Held * Address * Phone Number * Reason For Leaving * Were you subject to the FMCSRs while employed here? * 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 Add 5th Employer * Yes No Employer Name * Start Date * End Date * Position Held * Address * Phone Number * Reason For Leaving * Were you subject to the FMCSRs while employed here? * 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 Add 6th Employer * Yes No Employer Name * Start Date * End Date * Position Held * Address * Phone Number * Reason For Leaving * Were you subject to the FMCSRs while employed here? * 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 DRIVING EXPERIENCE Check all Classes You Have Experience With Class Of Equipment * Tractor & Semi-Trailer Tractor & Two Trailers Tractor & Triple Trailers OtherOther Tractor & Semi-Trailer Start Date * Tractor & Semi-Trailer End Date * Approximate Number of Miles Driving Tractor & Semi-Trailer * Tractor & Two Trailers Start Date * Tractor & Two Trailers End Date * Approximate Number of Miles Driving Tractor & Two Trailers * Tractor & Triple Trailers Start Date * Tractor & Triple Trailers End Date * Approximate Number of Miles Driving Tractor & Triple Trailers Other Start Date * Other End Date * Approximate Number of Miles Driving Other * List states operated in, for the last five (5) years: * List special courses/training completed (PTD/DDC, HAZMAT, ETC) List any Safe Driving Awards you hold and from whom: Accident Record for past three (3) years: Have you been involved in an accident in the past 3 years? * Yes No Date Of Accident * Nature of Accident (Head on, rear end, etc) * Location of Accident * Number of Fatalities * Number of People Injured * Add 2nd Accident? * Yes No Date Of Accident * Nature of Accident (Head on, rear end, etc) * Location of Accident * Number of Fatalities * Number of People Injured * Add 3rd Accident? * Yes No Date Of Accident * Nature of Accident (Head on, rear end, etc) * Location of Accident * Number of Fatalities * Number of People Injured * Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations): Do you have a traffic conviction or forfeiture in the last 3 years? * Yes No Date * Location * Charge * Penalty * Add 2nd conviction or forfeiture? * Yes No Date * Location * Charge * Penalty * Add 3rd conviction or forfeiture? * Yes No Date * Location * Charge * Penalty * Driver’s License (list each driver’s license held in the past three(3) years: State * License * Type * Endorsments * Expiration Date * 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 Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)? * Yes No Have you ever been convicted of a felony? * Yes No If the answers to any questions listed above are “yes”, give details PERSONAL REFERENCES List three (3) persons for references, other than family members, who have knowledge of your safety habits. Name * Address * Phone Number * Name * Address * Phone Number * Name * Address * Phone Number * To Be Read and Agreed to by Applicant: It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my application file. It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. 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. Applicant Agreement * I Agree Submit If you are human, leave this field blank.
