COMMERCIAL DRIVER APPLICATION

Application Form

COMMERCIAL DRIVER APPLICATION
Company
Address
City
State
Zip
APPLICANT INFORMATION
Date
Date Format: MM slash DD slash YYYY
Position applying for:
- Contractor
- Driver
- Contractor's Driver
Name
Phone
Emergency Phone
Age
Date Of Birth
SS#
(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 3 Addresses
Have you ever worked for this company before?
- Yes
- No
If yes, give dates:
Reason for leaving?
Education History

Please choose the highest grade completed:
Grade School:
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
College:
- 1
- 2
- 3
- 4
Post Graduate:
- 2
- 2
- 3
- 4
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.
Mo/Yr From:
Mo/Yr To:
Position Held
Present or Last Employer Name:
Address
Reason for Leaving
Company Phone
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
Mo/Yr From:
Mo/Yr To:
Position Held
Present or Last Employer Name:
Address
Reason for Leaving
Company Phone
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
Mo/Yr From:
Mo/Yr To:
Position Held
Present or Last Employer Name:
Address
Reason for Leaving
Company Phone
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:
Have you driven a Straight Truck?
- Yes
- No
From Date:
To Date:
Approximate Number of Miles:
Have you driven a Tractor & Semi Trailer?
- Yes
- No
From Date:
To Date:
Approximate Number of Miles:
Have you driven a Tractor & Two Trailers?
- Yes
- No
From Date:
To Date:
Approximate Number of Miles:
Have you driven a Tractor & Triple Trailers?
- Yes
- No
From Date:
To Date:
Approximate Number of Miles:
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: (attach sheet if more space is needed):
Date of Accident & Nature of Accident (Head on, rear end, etc)
Location of Accident:
# of fatalities & # of people injured:
Date of Accident & Nature of Accident (Head on, rear end, etc)
Location of Accident:
# of fatalities & # of people injured:
Date of Accident & Nature of Accident (Head on, rear end, etc)
Location of Accident:
# of fatalities & # of people injured:
Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):
Date
Location
Charge/Penalty
Date
Location
Charge/Penalty
Date
Location
Charge/Penalty
Driver’s License (list each driver’s license held in the past three(3) years:
State
License #
Type
Endorsements
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:
Job References

List three (3) persons for references, other than family members, who have knowledge of your safety habits.
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
To Be Read and Signed 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 Signature:
Date:
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Application Form

COMMERCIAL DRIVER APPLICATION

APPLICANT INFORMATION

Education History

Employment History:

Driving Experience:

Accident Record for past three (3) years: (attach sheet if more space is needed):

Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):

Driver’s License (list each driver’s license held in the past three(3) years:

Job References

To Be Read and Signed by Applicant: