Driver’s Application For Employment

Date of Application

Name*

First Middle Last

Social Security Number*

Phone*

Email

Address*

Street Address Address Line 2 City State ZIP Code

Has this been your address for the past three years?*

Yes
No

Previous Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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

Yes
No

Date of Birth

Can you provide proof of age?

Yes
No

Have you worked for this company before?

Yes
No

Where have you worked?

Date (from)

Date (to)

Rate of Pay?

Position you held?

Reason for leaving?

Are you now employed?

Yes
No

How long since last employment?

Who referred you?

Rate of pay expected:

Is there any reason you might know of that might inhibit you from performing the tasks related to the position for which you have applied for?

Yes
No

Please explain based on what you understand those tasks are:

Notice to Applicant: Before you continue in filling out the remainder of this application, we must inform you that the information you have provided so far, and any and all information you are about to disclose, in accordance with 49 CFR Part 391.21(b)(10) of the Federal Motor Carrier Safety Regulations (FMCSRs), may be used and your previous employers “will be” contacted for the purpose of investigating your safety performance history as required by 391.23(d) and 391.23(e) of the FMCSRs. If it has not already been provided for you, please ask for a written copy of your “due process rights” regarding any and all information obtained during the processing of your history as specified in 391.23(l).

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years.
Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on the employers for whom the applicant operated such vehicle.
Note: List employers in reverse order, starting with the most recent.

Name

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Contact

Were you subject to the FMCSRs in this position while employed by this previous employer?
Yes
No
§391.21(b)(10)(iv)(A)

From:

To:

Position Held

Salary/Wage

Reason for Leaving

Was this position designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing? §391.21(b)(10)(iv)(B)
Yes
No

* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

EXPERIENCE AND QUALIFICATIONS - OTHER

Accident record for past three (3) years or more. Attach sheet if more space is needed.

EDUCATION

Education Level

Highest Grade Completed

Last School Attended (Name, City, State)

EXPERIENCE AND QUALIFICATIONS - DRIVER

Driver Licenses

State

License #

Type

Expiration Date

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Yes
No

Statement

Has any license, permit, or privilege ever been suspended or revoked?
Yes
No

Statement

Driving Experience (Check all that apply)
Straight Truck
Tractor-Trailer
Doubles/Triples
Other

Type of Equipment (Van, Tank, Flat, Etc.)

Date (From)

Date (To)

Approx. No. of Miles (Total)

Type of Equipment (Van, Tank, Flat, Etc.)

Date (From)

Date (To)

Approx. No. of Miles (Total)

Type of Equipment (Van, Tank, Flat, Etc.)

Date (From)

Date (To)

Approx. No. of Miles (Total)

Type of Equipment (Van, Tank, Flat, Etc.)

Date (From)

Date (To)

Approx. No. of Miles (Total)

List states you operated in for the last five years

Show special courses or training that will help you as a driver

Show any trucking, transportation, or other experience that may help in your work for this company

List courses and training other than that shown elsewhere in this application.

List special equipment or technical materials you can work with (other than those already shown)

TO BE READ AND SIGNED BY APPLICANT

Sec. 40.25(j): As the employer, you must also ask the employee whether he or she has tested positive or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety sensitive functions for you until and unless the employee documents successful completion of the returnto-duty process. (see Sec. 40.25(b)(5) and (e)).

Have you ever tested positive or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?
Yes
No

If you answered yes, can you provide/obtain proof that you have successfully completed the DOT return-to-duty requirements?
Yes
No

This certifies that I completed this application, and that all entries and information documented by me are true and complete to the best of my knowledge. By my signature heretofore, I acknowledge having been given by this carrier which has presented me with this application, a statement of my right to due process as outlined by all parts of 49 CFR Part 391.23 of the Federal Motor Carrier Safety Regulations effective October 29, 2004. Having made this acknowledgment, I therefore authorize you to make such previous employment and background investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary to arrive at a possible employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended). I understand that false or misleading information given in my application or interviews may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

Date

Applicant's Signature

Driver’s Application For Employment