Applications

Application

20%

Instructions to Applicant
Please answer all questions. If the answer to any question is “No” or “None,” do not leave the item blank, but write “No” or “None.” This is important! *The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.
Date
Check One:
- Contractor
- Driver
Name
First Middle Last
Phone
Emergency Phone Number
Age
Date of Birth
Physical Exam Expiration Date
Current & Three Years Previous Address
Street Address City, State, Zip From (mo/yr) To (mo/yr)
Education
Highest Grade Completed in Grade School
Highest Grade Completed in College

Previous Employers
Give a complete record of all employment for the past three years, including any unemployment of self employment, and all commercial driving experience for the past ten years.
Name of Previous Employer
Previous Employer
Address of Previous Employer
Street Address City State / Province / Region ZIP / Postal Code
Phone Number of Previous Employer
Starting Date
End Date
Position Held
Reason for Leaving
Add another previous employer
Remove this employer

Driving Experience
Class of Equipment
Date (From)
Date (To)
Approximate Number of Miles (Total)
Please enter a value greater than or equal to 0.
List states operated in for the last five years:
List special courses/training completed (PTD/DDC, Haz Mat, etc):
List any Safe Driving Awards you hold and from whom:
Accident Record for past three years
Date of Accident Nature of Accidents (Head on, rear end, upset, etc.) Location of Accident # of Fatalities # of People Injured
Traffic Convictions and Forfeitures for the last three years (other than parking violations)
Date Location Charge Penalty
Driver’s License (list each driver’s license held in the past three years)
State License # Type Endorsements Expiration Date
A. Have you ever been denied a license, permit of privilege to operate a motor vehicle?
- Yes
- No
B. Has any license, permit or privilege ever been suspended or revoked?
- Yes
- No
C. Is there any reason you might be unable to perform the function of the job for which you have applied (as described in the job description)?
- Yes
- No
D. Have you ever been convicted of a felony?
- Yes
- No
If the answers to A,B,C, or D is “YES”, give details

Personal References
List three persons for references, other than family members, who have knowledge of your safety habits.
Personal Reference One
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone
Personal Reference Two
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone
Personal Reference Three
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone

To Be Read and Signed by Applicant
It is agreed and understood that any misrepresentation given on this application for qualification shall be considered an act of dishonesty. I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me. It is agreed and understood that if qualified to operate motor carrier equipment, I may be on a probationary period, during which 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's Electronic Signature
Date