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Driver Employment
DRIVER EMPLOYMENT APPLICATION
Driver Employment
First Name
*
Middle Name
Last Name
*
Tags
Phone
Email
*
Date of Birth
Social Security #
Date of Application
Position Applied For
*
Date Available for Work
Previous Residence Information
Street Address
*
City
*
State
*
Zip Code
*
# of Years at Address
*
Add
Remove
Previous License Information
State
*
License
*
Type/Class
*
Endrosement
*
Expiration Date
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Driving Experience
Class of Equipment
Straight Truck
Tractor & Semi-Trailer
Tractor & Two Trailer
Tractory & Tanker
Other
Type of Equipment
*
Date From
Date To
Approx # of Miles (Total)
*
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ACCIDENT RECORD FOR THE PAST 3 YEARS
Date
NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.)
*
FATALITIES
*
INJURIES
*
CHEMICAL SPILLS (Y/N)
*
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TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
Dates
VIOLATION
*
STATE OF VIOLATION
*
PENALTY (Forfeited bond, collateral and/or points)
*
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Remove
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
EMPLOYMENT HISTORY
Employer Info
Name
*
Phone
Address
*
Position Held
*
From
To
Reason for Leaving
*
Salary
*
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)
*
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
Yes
No
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?
Yes
No
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Remove
Education History
School
School
High School
Other
Name & Location
*
Course of Study
*
Years Completed
*
Are your Graduate
Yes
No
Details
*
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Remove
Other Qualifications
driver license
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Maximum upload size: 516MB
medical card
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Maximum upload size: 516MB
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.
*
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