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Driver Application

Driver Application

Driver Application

Step 1 of 8

12%

Do not fill this form out if you're a solicitor.
Name*
First Middle Last
Date of Birth (MM/DD/YYYY)
Positions Applied For:
Email*
Phone*

List your address of residency for the past 3 Years (Leave blank if not applicable)
Current Address
Address Line 2 City State / Province / Region ZIP / Postal Code Country
Previous Address 1
Address Line 2 City State / Province / Region ZIP / Postal Code Country
Previous Address 2
Address Line 2 City State / Province / Region ZIP / Postal Code Country

Experience and Qualification - Driver
Driver License #1
State:
License Number:
Type:
Expiration Date:
Driver License #2
State:
License Number:
Type:
Expiration Date:
Driver License #3
State:
License Number:
Type:
Expiration Date:

Are you employed?
If not, how long since leaving your last employment?
Is there any reason you might be unable to perform the function of the job for which you have applied?
- Yes
- No
If yes, explain if you wish.
Employment History
All driver applicants must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, phone numbers, city, state, and zip codes. Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall 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 as necessary.)
Employer
Name
First Last
Address
City State / Province / Region ZIP / Postal Code
Contact Person
First Last
Phone
Were you subject to the FMCSR's while employed?
- 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
Date
From:
To:
Position Held:
Salary/Wage:
Reason For Leaving:
Add another?
- Yes
Employer #2
Name
First Last
Address
City State / Province / Region ZIP / Postal Code
Contact Person
First Last
Phone
Were you subject to the FMCSR's while employed?
- 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
Date
From:
To:
Position Held:
Salary/Wage:
Reason For Leaving:
Add a Third?
- Yes
Employer #3
Name
First Last
Address
City State / Province / Region ZIP / Postal Code
Contact Person
First Last
Phone
Were you subject to the FMCSR's while employed?
- 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
Date
From:
To:
Position Held:
Salary/Wage:
Reason For Leaving:

Accident Record for the Past 3 Years (Add more if needed)
Accident 1
Accident Date
Nature (Roll over, Rear end, etc.):
Fatalities:
Injuries:
Add another Accident?
- Yes
Accident 2
Accident Date
Nature (Roll over, Rear end, etc.):
Fatalities:
Injuries:

Driving Experience (Leave empty if not applicable)
Straight Truck
Class of Equipment:
Type of Equipment:
Dates (From/To):
Miles Driven:
Tractor Semi-Trailer
Class of Equipment:
Type of Equipment:
Dates (From/To):
Miles Driven:
Tractor 2 Trailer Combo
Class of Equipment:
Type of Equipment:
Dates (From/To):
Miles Driven:
Other
Class of Equipment:
Type of Equipment:
Dates (From/To):
Miles Driven:

List all Traffic Fines and Forfeitures For the Past 3 Years
Fine/Forfeiture 1
Location
Date of Fine
Charge
Penalty
Add a Second Fine?
- Yes
Fine/Forfeiture 2
Location
Date of Fine
Charge
Penalty
Add a Third Fine?
- Yes
Fine/Forfeiture 3
Location
Date of Fine
Charge
Penalty

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
- Yes
- No
Has any license you held ever been suspended or revoked?
- Yes
- No
If you answered yes to any of the above, give details below.
Have you ever tested positive, or refused to test, on any pre-employment drug test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug testing rules during the past two years?
- Yes
- No
If you answered yes can you provide/obtain proof that you've successfully completed the DOT return-to-duty requirements?
- Yes
- No
Have you ever been convicted of a felony?
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.

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