Employment Application Form Employment Application For CDL/Transport Drivers Name First Middle Maiden (If any) Last Address Street City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip How long have you been at this address? Date Of Birth Social Security Number Email Address Phone Number Do you have a valid license? Yes No License Information Section 383.21 FMCSR states: "No person who operates a commercial motor vehicle shall, at any one time, have more than one drivers license." I certify that I do not have more than one license (Please initial) License Number License Type State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Expiration Date Driving Experience Class Of Equipment Equipment Type Dates Approx No. Miles Driven Straight Truck Tractor & Semi-Trailer Tractor Two Trailers Other Accident Record For Past 3 Years Or More Date Of Accident Nature Of Accident Number Of Fatalities Number Of Injuries Chemical Spill Yes No Yes No Yes No Traffic Convictions Or Forfeitures Over The Past 3 Years (Other than parking violations) Date Convicted State Of Violation Violation Penalty (Forfeited bond, collateral, points, etc.) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Employment Record Applicants that desire to drive in interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial years (total of ten years employment record) Must list the complete mailing address: street number and name, city, state and zip code. Current Employer Name Address Phone Position Held From To Salary Reasons For Leaving Any Gaps In Employment And/Or Unemployment Must Be Explained. Include Dates (Month/Year) And Reason. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSR) while employed by the previous employer? Yes No Was the previous job position designated as a safety sensitive function in any DOT regulator mode, subject to alcohol and controller substance testing requirements as required by 49 CFR Part 40? Yes No Last Employer Name Address Phone Position Held From To Salary Reasons For Leaving Any Gaps In Employment And/Or Unemployment Must Be Explained. Include Dates (Month/Year) And Reason. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSR) while employed by the previous employer? Yes No Was the previous job position designated as a safety sensitive function in any DOT regulator mode, subject to alcohol and controller substance testing requirements as required by 49 CFR Part 40? Yes No Last Employer Name Address Phone Position Held From To Salary Reasons For Leaving Any Gaps In Employment And/Or Unemployment Must Be Explained. Include Dates (Month/Year) And Reason. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSR) while employed by the previous employer? Yes No Was the previous job position designated as a safety sensitive function in any DOT regulator mode, subject to alcohol and controller substance testing requirements as required by 49 CFR Part 40? Yes No To Be Read And Signed By Applicant I authorize you to make sure investigations and inquires to my personal, employment, financial or medical history and other related matters as may be necessary in arriving as an employment decision. (Generally, inquires regarding medical history will be made only if and after a conditional offer of employment is has been extended.) I herby release employers, schools, health care providers and other persons from liability in responding to inquires and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required t abide by all rules adn regulations of the Company. "I understand the information I provide regarding my current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that O have the right to: Review information provided by current/previous employers Have errors in the information corrected by previous employers and those previous employers to re-send the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information." Date Applicant's Signature This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Date Applicant's Signature Note: A motor carrier mya require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.
