Job Application

Application for Employment

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered fro all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

Step 1 of 4

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Position(s) Applied for:*
Name*
First Last
Social Security No.:*
Phone Number:*
List your addresses of residency for the past 3 years.
Current Address:*
Street Address City State ZIP Code
How Long? (yr/mo):*
Previous Address (if applicable):
Street Address City State ZIP Code
How Long? (yr/mo):
Previous Address (if applicable):
Street Address City State ZIP Code
How Long? (yr/mo):
Previous Address (if applicable):
Street Address City State ZIP Code
How Long? (yr/mo):

APPLICANT
Do you have the legal right to work in the United States?*
Date of Birth (Required for Commercial Drivers):*
Can you provide proof of age?
Have you worked for this company before?
If so, where?
Start date:
End date:
Rate of pay:
Position:
Reason for leaving?
Are you currently employed?
If not, how long has it been since you were last employed?
Who referred you?
Expected rate of pay:
Have you ever been bonded? (Answer only if a job requirement).
If so, name of bonding company:
Have you ever been convicted of a felony?
If so, please explain fully: (Conviction of a crime is not an automatic bar to employment - all circumstances will be considered).
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)?
If yes, explain if you wish:

EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 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 on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet if necessary)
Employer
Name of Employer:
Address
Street Address City State ZIP Code
Contact person:
First Last
Phone:
Start date:
End date:
Position held:
Salary/Wage:
Reason for leaving?
Were you subject to the FMCRs+ while employed?
Type of trailer pulled?
Was your job designated as a safety-sensitive function if any dot-regulated mode subject to the Drug and Alcohol testing requirements of 49 CFR Part 40?
Employer
Name of Employer:
Address
Street Address City State ZIP Code
Contact person:
First Last
Phone:
Start date:
End date:
Position held:
Salary/Wage:
Reason for leaving?
Were you subject to the FMCRs+ while employed?
Type of trailer pulled?
Was your job designated as a safety-sensitive function if any dot-regulated mode subject to the Drug and Alcohol testing requirements of 49 CFR Part 40?
Employer
Name of Employer:
Address
Street Address City State ZIP Code
Contact person:
First Last
Phone:
Start date:
End date:
Position held:
Salary/Wage:
Reason for leaving?
Were you subject to the FMCRs+ while employed?
Type of trailer pulled?
Was your job designated as a safety-sensitive function if any dot-regulated mode subject to the Drug and Alcohol testing requirements of 49 CFR Part 40?
Employer
Name of Employer:
Address
Street Address City State ZIP Code
Contact person:
First Last
Phone:
Start date:
End date:
Position held:
Salary/Wage:
Reason for leaving?
Were you subject to the FMCRs+ while employed?
Type of trailer pulled?
Was your job designated as a safety-sensitive function if any dot-regulated mode subject to the Drug and Alcohol testing requirements of 49 CFR Part 40?
Employer
Name of Employer:
Address
Street Address City State ZIP Code
Contact person:
First Last
Phone:
Start date:
End date:
Position held:
Salary/Wage:
Reason for leaving?
Were you subject to the FMCRs+ while employed?
Type of trailer pulled?
Was your job designated as a safety-sensitive function if any dot-regulated mode subject to the Drug and Alcohol testing requirements of 49 CFR Part 40?
Employer
Name of Employer:
Address
Street Address City State ZIP Code
Contact person:
First Last
Phone:
Start date:
End date:
Position held:
Salary/Wage:
Reason for leaving?
Were you subject to the FMCRs+ while employed?
Type of trailer pulled?
Was your job designated as a safety-sensitive function if any dot-regulated mode subject to the Drug and Alcohol testing requirements of 49 CFR Part 40?

30 DAY GAP IN EMPLOYMENT
List all gaps in your employment work history during the last ten (10) years that are 30 days or greater. Be specific as to the reason for the gaps in employment and what duties you performed in the space provided below.

From	To	Reason for Gaps of 30 days of more

ACCIDENT RECORD
For past 3 years or more (attach sheet if more space is needed) if none, write NONE.
Date Nature of Accident Fatalities Injuries Hazardous Material Spill
TRAFFIC CONVICTIONS
And forfeitures for the past 3 years (other than Parking Violations). If none, write NONE.
Location Date Charge Penalty
EXPERIENCE AND QUALIFICATIONS
List all driver licenses or permits held in the past 3 years.
State License No. Type Expiration Date
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
B. Has any license, permit, or privilege ever been suspended or revoked?
If you answered "yes" to either A or B, please provide details.
DRIVING EXPERIENCE
Straight truck (Yes/No) Type of Equipment (Van,Tank,Flat,Dump,Refer) From (Mo/Yr) To (Mo/Yr) Approx. No. of Miles (Total)
Tractor and Semi-Trailer (Yes/No) Type of Equipment (Van,Tank,Flat,Dump,Refer) From (Mo/Yr) To (Mo/Yr) Approx. No. of Miles (Total)
Tractor - Two-Trailers (Yes/No) Type of Equipment (Van,Tank,Flat,Dump,Refer) From (Mo/Yr) To (Mo/Yr) Approx. No. of Miles (Total)
Tractor - Three-Trailers (Yes/No) Type of Equipment (Van,Tank,Flat,Dump,Refer) From (Mo/Yr) To (Mo/Yr) Approx. No. of Miles (Total)
Motorcoach - School Bus (Yes/No) More than 16 passengers From (Mo/Yr) To (Mo/Yr) Approx. No. of Miles (Total)
Motorcoach - School Bus (Yes/No) More than 8 passengers From (Mo/Yr) To (Mo/Yr) Approx. No. of Miles (Total)
Other Type of Equipment (Van,Tank,Flat,Dump,Refer) From (Mo/Yr) To (Mo/Yr) Approx. No. of Miles (Total)
List states operated in for the last five years:
List special courses or training that will help you as a driver:
List safe driving awards that you hold and from whom:
Explain any trucking, transportation or other experience that may help 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
Highest school grade completed:
College:
Last school attended:
Name City State
TO BE READ AND SIGNED BY APPLICANT
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.
Name
First Last
Date

Job Application

Application for Employment

Step 1 of 4

APPLICANT

EMPLOYMENT HISTORY

30 DAY GAP IN EMPLOYMENT

ACCIDENT RECORD

TRAFFIC CONVICTIONS

EXPERIENCE AND QUALIFICATIONS

DRIVING EXPERIENCE

EDUCATION

TO BE READ AND SIGNED BY APPLICANT

CONTACT US

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