FIRST NAME

MIDDLE NAME

LAST NAME

PHONE

EMAIL

DATE OF BIRTH

SOCIAL SECURITY #

DATE OF APPLICATION

POSITION APPLIED FOR

DATE AVAILABLE FOR WORK

Do you have legal right to work in the United States?

YesNo

Attach additional sheet if more space is needed

STREET

CITY

STATE

ZIP CODE

# OF YEARS AT ADDRESS

CURRENT

MAILING

PREVIOUS

PREVIOUS

PREVIOUS

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; attach

additional sheets if needed.

STATE

LICENSE #

TYPE/CLASS

ENDORSEMENTS

EXPIRATION DATE

PREVOIUSLY HELD LICENSES

CLASS OF EQUIPMENT

TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)

DATE FROM

DATE TO

APPROX # OF MILES (TOTAL)

STRAIGHT TRUCK

TRACTOR & SEMI-TRAILER

TRACTOR & 2 TRAILERS

TRACTOR & TANKER

OTHER

Attach additional sheet if more space is needed. Check this box if none ☐

DATES(List most recent first)

NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.)

# FATALITIES

# INJURIES

CHEMICAL SPILLS (Y/N)

Attach additional sheet if more space is needed. Check this box if none ☐

DATE CONVICTED(Month/Year)

VIOLATION

STATE OF VIOLATION

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

YesNo

Has any license, permit, or privilege ever been suspended or revoked? If yes, explain

YesNo

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

NAME

PHONE

ADDRESS

POSITION HELD

FROM MO/YR

TO MO/YR

REASON FOR LEAVING

SALARY

EXPLAIN ANY GAPS INEMPLOYMENT (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

YesNo

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?

YesNo

NAME

PHONE

ADDRESS

POSITION HELD

FROM MO/YR

TO MO/YR

REASON FOR LEAVING

SALARY

EXPLAIN ANY GAPS INEMPLOYMENT (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

YesNo

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?

YesNo

THIRD (MOST RECENT) EMPLOYER

NAME

PHONE

ADDRESS

POSITION HELD

FROM MO/YR

TO MO/YR

REASON FOR LEAVING

SALARY

EXPLAIN ANY GAPS INEMPLOYMENT (Include month/year & reason)

EDUCATION

SCHOOL

NAME & LOCATION

COURSE OF STUDY

YEARS COMPLETED

GRADUATE

DETAILS

High School

YesNo

College

YesNo

Other

YesNo

OTHER QUALIFICATIONS

Please list any other qualifications that you have and which you believe should be considered.

TO BE READ AND SIGNED 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:

i) Review information provided by current/previous employers;

ii) Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; and

iii) 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 (printed)